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Miscellaneous - 318 MAIN STREET 4/30/2018 (2)
�8�AINREET2100000.0 1 Date 7- 11162 V40RT TOWN OF NORTH ANDOVER x PERMIT FOR PLUMBING This certifies that.<;;.�. . ......NDw.v I has permission to perform.....\j. ...YAra!Iu....................................................... plumbing in the buildings of...../^)" ........................................................................................ at.... ...................... N North Andover, Mass. ......... . . ... Fee...... J. —Lic. No. .�.I...... ................................... kUIMBING INSPECTOR U Check i941 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Of CITY ® _ MA DATE - 7 J �7/ PERMIT# JOBSITE ADDRESS / OWNER'S NAME POWNER ADDRESS TEL —^ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: 1 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES13 NOD FIXTURES 1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ ( _ -_Tl, _ _ CA -JI DEDICATED GREASE SYSTEM ___ DEDICATED GRAY WATER SYSTEM 4 _f I __Jj _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOORIAREADRAIN _I __...__1 __J ___._J INTERCEPTOR(INTERIOR) KITCHEN SINK I J 1 ( _l ( 4 __.J LAVATORY ROOF DRAIN 1 ___1 -------J __—f -.-____f __._.! _ I .__.__.J .r._ E _._� .._.._..._f ___j I SHOWER STALL SERVICE/MOP SINK __j _____-j i TOILET ._._,_j ____ .___ l URINAL WASHING MACHINE CONNECTION ____ -------- WATER ___ ..... _. -----WATER NEATER ALL TYPES WATER PIPING OTHER L_ 14"x+ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Eg-NO IF YOU CHECKEDYES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY®- OTHER TYPE OF INDEMNITY D BOND Q 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 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 'Peoto to the best o knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia all Pertinen p visi of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME %/2y ��2 LICENSE# SIGNATURE MPU- JP D CORPORATIOND# PARTNERSHIPD#®LLC COMPANY NAME C-rFP f 0C.tJ4_)S d06-:Ljj ADDRESS CITY J STATE r ZIP I /S' Z- j EL FAX I E CELL EMAIL f ROUGH PLUMBING INSPEgITON NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECT . OTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT it PLAN REVIEW NOTES I i i I i The Commonwealth of Massachusetts Department of IndustrialAccidents z _ 1 Congress Street,Suite 100 Boston,ALL 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lel4ibl Name(Business/Organization/Individual): � 16[�l/f Address: 0 — City/State/Zip: 4 Phone#: Are you an employer?Check the appropriate b Type of project(required): 1.❑I am.a employer with employees(full and/or part-time).* 7. ❑New construction m a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. F1 Demolition 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11. Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not.those entities have employees. If the sub-coritractiors have employees,they must provide their workers'comp.policy number. I ain an employer that is providing workers'compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: (�i�// GG �_ �✓iU Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 319 City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a 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. I do hereby certify un e�zens and pen t' s o perjury that the information provided above is true and correct. Si nature: Date: Phone . g71,6 Official use only. Do not write in this area,to be completed by city or town official:. I City or Town: Permit/License# Issuing Authority(circle one): ; 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Contact Person: Phone#: r , -1 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract 6f hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into 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 Please fill-out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and-phone number(s)along with their certificate(s)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. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensationi policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance 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 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 that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or pen-nit 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 1 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 i y -r ;a COMMONWEALTH OF MASSACHS BOARD OF PLUMBERS :AND GASFJTTERS I �ISSUES,THE FOLLOWING LICENSE $ LI�E1V'SE'D AS A MASTER PLUMBS°R GE,RRY. L; DOWNS n ,, 107 FERRY RD` ,; W SA'L.1 SBURY MA 01952 257'2 . 1256.6` 05/0.I:k.1 210416 Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 001845- NORTH ANDOVER, MA 001845- "-I Insured: JOHN WARDEN and PAMELA WARDEN Property Address: 318 MAIN STREET,NORTH ANDOVER, MA Policy Number: HMA 0218407 Claim Number: BOS00044729 Date of Loss: 8/7/2014 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the.attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Holly Coughlin Claim Examiner 8/11/2014 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617)951-0.600 EXT 3026 Fax: (617),531-6684 , Email: Ho1lyCoughlin@SafetyInsurance.com 'i Date.. ........... d �aORTp TOWN OF NORTH ANDOVER p PERMIT FOR WIRING } �,SSACHUS� This certifies that .. .... � ...... `.�:�;�.,.es�� !............................. has permission to perform ...... -.._ .'................................................... ~' wiring in the building of.........:`.... :..�.J.....:................................................ at�"?/'J.... u�� w................................. .North Andover,Mass. ..................... Fee.`... .. ...... Lic.No?( 1t ' -?��.......................... ELEmicAL MpEc-= Check # 47 17 THE COMMONWEALTH OF MASSACHUSETTS Office Use only DEPARTNIENT0FPUBL1CS4F= Permit No. "-f'7tl 7 BOARDOFFIREPREVE MONREGULAHONS527CMRI Occupancy&Fees Checked APPLICATTONFOR PERMIT TO PERFORM CTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 �� G3 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (7 i�CJ Town of North Andover To the Inspector of Wires: The undersigned applies for permit to perform the electrical work described below. g PP P Location (Street&Number) IV Or ner or Tenant Owner's Address A-/11/ Y Is this permit in conjunction with a building permit: Yes No (C heck Appropriate Box) Utility Authorization No. Purpose of Building Existing Service 100 Ampsl/1�Volts Overhead Underground ED No. of Meters New Service Amps / Volts Overhead M Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work T( 7-GI 4.) Ute rrmn—,!' - No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA . No.of Lighting Fixtures `; Swimming Pool Above Below Generators KVA if— round ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones�e Tons Nb.of Disposals No.of Heat Total Total No.of Detection and Purrs-os Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER• i I-pstumceCowrage.Rum=tothelegtmmlmNofNbssa set Ctwallaws YES NO It awawaulLia AtyknuancePbhcyincchldulgComplete °��CovaageoritsabsTa vdegtuvalalt IhawwNllwdvaWpu4ofsametodrOffice.YFS U Ifyouhavecllr dYESPlea9eindt thetypeofmv ageby cl>ed*thebox IlVSURANCEOMER BOND � � ( S1ofY) Fxpitation Dak / ValueofEkOcalWok$ WotktoStatt lr�ctionPckRegt�d . Rough Signedunder�ieP�>alttesofPew- FIRM ej -FIRM NAME Lice sseNo. Licff � [ RPrS G'Ydh Signattue Lice>SeNo c9Z0 /�/ // G In / BtnnessTel No. `l7�d' �7 Z/ Aaat c /1 V�V/�� % /'7/'t�/�i Y��` ! At Tel No. OWfqffN INS[1RANCE WAIVER;I am awate that thelicerse does nothave the ins rarm wveage orits subsImbal equivalit as regttited by Massxh sL s Geeul Laws and my 'gl�ahue on this t waives this tegmernmt (Pleas eck one) O Agent Telephone No. Al PERMIT FEE$ lgn tore o wner r WgeFt G The Commonwealth of Massachusetts . ; d Department of Industrial Accidents Office of Investigations Boston, Mass. 02919 Workers'Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner pei forming all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address City Phone#-. Insurance.Co. Policv# Company name: Address City: Phone#• Insurance Co. Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to-the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment_as weD_as.civil.penattiesin.2helmnda_STOP.WORK..ORDFR and_a.fine_of..($1-00-0o)aiday.against.me. understand that a copy of this statement may be forwarded to the Office of Investigations of the MA for coverage verification. l do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature pate Print name Pbone.# Official use only do not write in this area to be completed by city or town officiar City or Town Permit/Licensi ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other Date. .��:.� .- � N° 43u1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING . Scmus� This certifies that . . l!.tom"�. . .. . . . . . . . . . . has permission to perform . . . . . . {.. ..... . . . . . . . . . . . plumbing in the buildings of . . .').�.`. . !. . . . . . . . . . . . . . . . . . . . . . at . . . .3. !. ". . .f-z . �!!.'. . . . . . . . . . . . . .. North Andover, Mass. Fee. . . . r. '.Lic. No.. . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # f WHITE: Applicant CANARY: Building Dept. PINK:Treasurer t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUM 3WG (Type print) NORTH ANDOVER,MASSACHUSETTS �-* Date Building Locati�u Owners Nair Permit Amount,00- Type of Occupancy ^°� New ri Renovation Replacement Plans Sub mittee�Y s E] No F1 ES z z � H a � w � U za O W W k4 z FF H H q S1:B>eM R4SEMM M RO(R Z�D H-OCK 3M]LOt 41H RD(R sUi IM snH RfM 7M rLoaZ SII3 FIOQt (Print or type) �/��� � Check one: Certificate Installing Company am e Corp. Address Partner. Business Telephone Firm/Co. Name of.Licensed Plumber. Insurance Coverage: Ind' tothe a of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigne ,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner F1 Agent I hereby certify that all of the details and information I have submitted(or entered)in bove application are true and accurate to the best of my knowledge and that all plumbing workand ins 1 do s performed un a ennit for this application will be in compliance with all pertinent provisions of State Plumbin e,a er 142 of General Laws. By: o icense r Type of Plum ing License Title City/Town icense um er Master ❑ Journeyman APPROVED(OFFICE USE ONLY Location l IPA f V sf--- No. � � Date i NORTIy TOWN OF NORTH ANDOVER O:�t.•o ,•1{.O C? •. • O� " Certificate of Occupancy $ CHU <� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # job 07, 6-- 14 6 '— 2 Building Inspector TOWN OF NORTH ANDOVER A BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: � Building Commissioner/Inspector of Buildings Date SECTION 1-SITE INFORMATION 1.1 Property Address, 1.2 Assessors Map and Parcel Number: C Map Number Parcel Number rc- 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Required Provide Recored. Provided Required Provided. C 1.7 Water S AG.I.C.40. 54 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Supply ) Public ❑ Private ❑ Zona Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ 1 a� SECTION 2-PROPERTY OWNERSHMAUTHORIZED AGENT 1 _ 2.1 Owner of Record t Name(Print) Address for Service tF -73 o -7 �+� Signature / Telephone j 2.2 Owner of Record- Q Name Print Address for Service: C 2 Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Co structio upervi Not Applicable ❑ am / j Licensed Const ction St rvisor: G` License Number Address (� H 73y-2 Expiration Date Signature Telephone ra 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name G ,7.—b� / Registration Number 17 Address �'l �-C�� /`� I �U 7 COE Expiration Date Si nature 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.......0 SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ `Alterations(s) ❑ Addition ❑ Accessory Bldg. 0 Demolition ❑ Other ❑ Specify Brief Description of/Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS ltem Estimated Cost(Dollar)to be I. NEW I= Completed b ermit a licant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC 5 Fire Protection 4 44Q ` 6 Total 1+2+3+4+5 i Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CON OR APPLIES FOR BUILDING PERMIT i as Owne/Authorized Agent of sub ct property Hereby auth ' e ' My behalf,in all matters relative to work authorized by this building permit application. ~ Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, ,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 Print Name Signature of Owner/Aent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TR%4BERS 1 ST 2ND 3 RD SPAN DMIENSIONS OF SILLS DIMENSIONS OF POSTS DI-tvIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CFMVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover0� tkO RTH � Building Department 0 27 Charles Street _ North Andover, Massachusetts 01845 (978) 688-9545 Fax(978) 688-9542S�AQs�TED KP�y�� BCH DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of. Building permit the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in/at: Facility location ignature o pplic tf 6/ « Ila I Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Please Print Name 6A c' J Ct�til1�1 Location: ►N S City /-J"d C1,t2 Phone (s J -7 3 o - 71 am a homeowner performing all work myself. sole proprietor and have no one working in any capacity am an employer providing workers'compensation for my employees working on this job. Company name: ZMC'_ C- c ? Address Q__7 D ( City. -�.'T�� ���� VL1 00V Phone#: r 3U- Insurance Co. �I(L-e LA4-S Policy# Company name: Address Citi Phone#: Insurance Co Policy# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of($100.00)a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify and sins and pen ies f per' th t th ation provided above is true and correct Si nature Date 9 \ � el Print name 4-5-90AA `'e1-1 __3 61�,4 Phone-# C 00V' 173 d Official use only do not write in this area to be completed by city or town official' ❑ Building Dept []Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION I t ] BOARD OF BUILDING REGULATIONS License: CONSTR=ON SUPERVISOR Number: CS 036863 Birthdate: 06/04/1960 i ! Expires:06/04/2002 Tr.no: 26448 _.Restricted To: 00 BRADLEY J JONES 97 DRUID NTLI.RD i METHUEN, W.A 01844 Administrator it i ✓�LS(Y3iYl1EPft!l4L7�R O�JIi.[7.k�q �j < HONE IHPRaVENENi CONTRACTOR , Registration: Ii1359 Expiration: 9126101 ' M v Type: GBA . r I JONES b CO Gam , BRADLEY JONES ADMINISTRATOR 97 DRUID HILL RD HEIHUEN MA 0144 FORTH own . of _ ' - 4 over No. /y8 y ��''��/ �'o - IC over Mass. COC HIC WIPK V 1 1 ADRATE D S H BOARD OF HEALTH P. ERMIT T Food/Kitchen Septic System WO' BUILDING INSPECTOR qWWS THIS CERTIFIES THAT......... /buildings ..... . ... . . . ....... ..... Foundation has permission to erect... � � on , �. .... Rough .. ... ...... . .. . ........ .............. to be occupied as..........................�........... Chimney provided that the person accepting this pe shall in every resp ct conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and-Construction of Buildings in the Town of North Andover. � � � � � � PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT 1 EX � ��� Final S IN 6 MONTHS UNLESS CONSTRUCTION ST TS 0 ELECTRICAL INSPECTOR Rough ............ ....... .......... .... ....... Service .. . .. . .. ............... ...... .......... DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough nal No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE smoke Det. • a M�SSACHIJSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTIN() � (Print or Type) NORTH ANDOVER Mass. Date -,Z3 building Location �'j ':�� "� Permit # 13 iSUV .� Mai Own rs Name . Y New Renovation Q Replacement Plans Submitted D �~ y FIXTUR=Is N W N Cf U Qr f— C F uNa p U Ca f" .e S N w a m m t- < m o o z t- tL w � w w t-. N 0. W 4 N N t3 U w r r 4 0 O G �' to U.1 w m w z a :: a Q 'U Q to c� ts: 0 1•- z -1 H z �. W to ° o ? w r w J F- to W C tart j 4 a d o o iu SUR—RSTMT. BASEMENT I I ST FLOOR 2ND FLOOR ( I G1 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FtOOR (Print or Type) Check one: Certificate Installing Company Na «/gec.t,sSC4Zcti. Q Corp. Address S/ d. - Q Partner. N Q Firm/Co. Business Telephone: ��� _ Name of Licensed Plumber or Gas Fitter Insurance' Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond (Q Insurance Waiver: I , the undersigned, have been made aware that the licensee of this applicatio does of haveany one of the above three insura coverages.Signatur o owner agent of prop Owner Q Agent cn� I hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of mY knowledge and tUat all plumbing work and installations petformod under'Permit iueed fo: this applicatio wiU Uance Pau provisions of rho Massachusetts State Gas Cade acrd Qtapter 142 of the General Laws. By TYPE LICE SE: Plumber Title asfitter S ure of Li nsed Master Plumber or Gasfitter City/Town: ,,.-Journeyman APPROVED (OFFiCF- USE ONLY) License Nu ber AQ Date.. . .. ........ . ..... .. c 40RTN ,1.O TOWN OF NORTH ANDOVER ,a �Or PERMIT FOR GAS INSTALLATION �9SSACeHUSC ! / This certifies that :' CU CU has permission for gas installationl. .'f�,. !. C . . . . . .. . . . . . . . T in the buildings of . . . .. .. . . ... .f f: . . . : . ,. . . . . . . . . . ., . . . . .. at J S. . . . . . lf: . . . . ...! ✓. . . . . . . . . , North Andover, Mass. Fee. ! . . . . .-Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0� I GAS INSPECTOR C ' WHITE:Applicant -CANARY: Building Dept. PINK:Treasurer GOLD: File Location � `p,g No. Date &ORT" TOWN OF NORTH ANDOVER (� Otte°o „ Certificate of Occupancy $ Building/Frame Permit Fee $ �SJAGNUSEt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ ego r Water"Connection Fee $ TOTAL $ s" Building Inspector orc� .. .. Div. Public Works Eaa><i�' NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE -EMAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP DATE BOOK PAGE ZONE I SUB DIV. LOT NO. I LOCATION PURPOSE OF BUILDING 3) .? rn a-;� S � OWNER'S NAME w�,/ , '� ,/ J,.L NO. OF STORIES SIZE x L OWNER'S ADDRESS �/(✓���/� BASEMENT OR SLAB -- ARCHITECT'S NAME A J �.v�! SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME / y7"T� _ 1 /� / Co�iS� , 1 SPAN /P -- DISTANCE TO NEAREST BUILDING CT F✓ DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS LIX -C�-h 7 l� DISTANCE FROM LOT LINES -SIDES REAR " GIRDERS ' �/ /o ) , AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THIC NESS IS BUILDING NEW � 1177 `C0 SIZE OF FOOTING X I IS BUILDING ADDITION „ / MATERIAL OF CHIMNEY _ IS BUILDING ALTERATION 7 IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER \� S BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN.SEWER �952 c IS BUILDING CONNECTED TO NATURAL GAS LINE J INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST / PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SCjr. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY I''''"'YYYYYY"'''' ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR A DAT"EF D BOARD OF HEALTH 41fiGNATURE 5F OWft-R-O-R--XUTHORIZED AGENT OWNER TEL.#--- 10 1O n .TEL.# 02 6 7 FEE CONTR. ®����-�S LIC.# PLANNING BOARD PERMIT GRANTED / (O 19 BOARD OF SELECTMEN G BUILDING INSPECTOR Ii _ h BUILDING RECORD 1 OCCUPANCY 12 , SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION $ INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL K. PINE _ BRICK OR STONE HARDWD PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ Y. V? '/ FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROAM MODERN KITCHEN 4 WALLS 19 FLOORS CLAPBO 'DS B 1 2 3 DROP SI G CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING D ASBESTOS SIDING COMMGN _ VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH )3 FIX.) GAMBREL MANSARD TOILET RM. )2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd ELECTRIC 1� 13rd 11 NO HEATING y ..: ...- OR TJOS _.._ SERVICES,SNC. ENGWEERING 234 ESSEX SMASSAC}IUSE�S 4AGOR: ~gUit- G MORTG SOF PR�NC�P�q. y ADDRESS: if,�;f.+ .PG, PSN REFERENCE". \ DATE OF ` \ nspe°t on Was Pr s�of to be t.IOTE: This Monga9e a urp ses and 8�. 3g cifcally for mortgage purposes Engineenn9 O �Z relied upon a sury risibility for da r than the is n°mspo other Inc.acce said reliance by any°in connection with is �� sal drmongagee anage erg ng 1O said m°n9ag°r. I g� w - its pro mortgage f&0 0 lr TC' CERTIFICA i lON U 37 ^ z I ,f i`. rn accordance �x \ L , PecionwasWePared ageLoan \ �3 Cj 7 v . This M g' eros at Standal ass M Ursens Ass°°a ort a9 ted b and C v; Inc. �� witn the ado meets, Iuo�Land Surveyors !1 \ OG �I ' `cc i� TE`eAstrIN u tAL ures and E3 cSS lO sort' iHER S� _ 51 \ IppIN10N the Pr'nciPr t the local zoning oof outbuildings requirements o encroachments O `� y with the setand t tints eltheaW aY across proPe�lines / a'n irn rpVem t�� � '•' or imP �C� W LG, exceP.,as sh $�y1N Of Md azar H Area. ood �o,^ ®LSO' in a FI Area. ropertY Is nnta Flood Hazar eetermin e Flood property s insutfnk to rcie iTsz o f �j 3.Iniormauon Hazard' Federal d f{azard determin om late Flood Insurance Rate `i. Scale: r?I pate of P tan: �I `I l r•vk!Wr,.5. . •-•...a,ro�,i vL �o i.ni rr/1 cn NORTpl — Tox.A.rn ® 6 ndover No. 23 : 300 �; No � Date....::................. ....... NORTH °!<+`'°;•'"° TOWN OF NORTH ANDOVER ° p PERMIT FOR WIRING s i -' • s SS�CHU f This certifies that ... ✓:.... ...............!:. . .:...........:................................... has permission to perform ..... ...`........................................ ................... wiring in the building of. �..�..`..: .:.. ..�.'.... ....................................... at... '.!� .... i �.....}... .......................... .North Andover,Mass. . Fee..2.;........... Lic.No. .............. ................ .............................. ELEcmcAL INSPECTOR Check # -� G WHITE:Applicant CANARY: Building Dept. PINK:Treasurer 7HECOMMOAWE4LTHOFN—IA—&"CfIU'SE77S OfTce Use only DEPARTAIENTOFPUBLICS4FE77 Permit No. 3 O O 0 BOARD 0FFIREPREVENTI0NRWUMTI0A S 527CMR 120 Occupancy&Fees Checked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 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) Date_,, Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) - fr,J Owner or Tenant %�r�UiYI,C DOING 2, Owner's Address JCC Is this permit in conjunction with a building permit: Yes[Z] No r7 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps l�Volts Overhead Underground No.of Meters New Service Amps Volts Overhead Underground No.of Meters Number of Feeders and Ampacity II Location and Nature of Proposed Electrical Work 4231 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures J Swimming Pool Above Below Generators KVA ground 0 around No.of Receptacle Outlets J No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local MunicipalOther Connections ' No.of Water Heaters KW No.of No.of l Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER lt-&=oeCo PtnsttantbthetagmmicrtsdMmmdws&Gm3alLmvs IImeaam=tLmbTtyfi-sL=roePci ymdutiirrgCm#At Co►eagearitsabtiMerg.rivala# YES NO l ImewbmJJ validprafofsametothe0l$oe YES If}whmdxdwdYES,plem udr*fctyWofoowg bydterrgthe NR ANCE BOND r7 OTf 1F3tR M ftweSpeffy) E mD* Estim*d ValuedUeoftxal Wolk$ ( WotkooSlatt hspecticrtD*Requested Rough Final SFIRRMM Paialhes afps�ta� jJ� G,�2cC. _ lioa�seNa /`7 X 6 3 1; //���� Sigrlaane Lioa>SeNo BtsirmTdNa ra.72- 621-L r �z�r� SI L��-� Ll '25`5-'2-V Ate. ... 52 `/� AkTdNa �� -----.__.. OWNER'S MJRANCEWAIVER;I.ammmethattheLkeme theinstra=wma eorilsakswIialepMkrtasmoredbyN Laws "diatmys nai+hspem-dternwaitsthistecpmnc (Please check one) Owner Agent Telephone No. PERMIT FEE Location 3/Y .� No. b Z- Date NORTH TOWN OF NORTH ANDOVER 1 O 00 P + �o Certificate of Occupancy $ s�cNusEt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # � r 1 6630 // building Inspector' ` TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIJ RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r BUILDING PERMIT NUMBER. DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Q/ ,� I q N4LI K) �T z 0 L-��/ N. ANA— tb Ut� MA Map Number Parcel Numb; N. 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided RecjWred Provided 1.7 Water SupplyM.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes NO m 2.1 Owner of Record "-[A to Mmrint) Address for Service D �,e a hone 2.2 Owner of Recor . Name Print Address for Service: O Z M Signature Telephone M SECTION 3-CONSTRUCTION SERVICES 70 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: O License Number Mn Address D Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name m Registration Number r Address r Z Expiration Date ^ Signature Telephone Y/ 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 alta Hcable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Tddition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: fVML&t -- Kq v\', a uki(�, D Lk- t� n W- SVCUA 6&i SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be t3FFICIA;USE ONLY Completed by permit applicant .. , 1. Building (a) Building Permit Fee Multiplier 2 Electrical `X-V (b) Estimated Total Cost of t Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 0*� 5 Fire Protection 6 Total. I'+2+3+4+5 •• Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWXERS AGENTOR CONTRACTOR APPLIES F�ORr BUILDING PERMIT as Owner/Authorized Agent of subject property ereby uthoriz t act cin h, i all maaersre wotutho ed b this building permit application. JAI Si nature of Own Date SECTION 7b OWHORIZED AGENT DECLARATION I, 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 Print Name Si attire of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB RD SIZE OF FLOOR TIMBERS 1 2 3 SPAN DIMENSIONS OF SILLS DH\,IENSIONS OF POSTS DEv1ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ptORT11 Town of North Andover Building Department •� M-�. SAre. 27 Charles Street CHue ��SEts� North Andover MA 01845 Tel: 978-6889545 HOMEOWNER LICENSE EXEMPTION Please print. DATE (:�lp �OL) JOB LOCATION1z l Number Street Address Sectiorro Town "HOMEOWNER 'MAIn� � /n�� �- b l� NumberNAi Home Phone Work Phone PRESENT MAILING A DRESS ity Towh State Zip Co e ): The current exemption for"Homeowners"was extended to include owner-occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 109.1.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling,attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official, a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowne ' ifies that he/she understands the Town of No.Andover Building Department minimu inspe 'on procedures and requirements and that he/she will comply with said procedures a requi ments. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwelling 35,000 cubic feet, or larger,will be required to comply with State Building Code Section 127.0 Construction Control. NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of Facility) Si tore Permit Applicant Date e NOTE: Demolition permit from the Town of North Andover must be obtained for this project throw�the Office of the Building Inspector NORTH ToVM of Andover 0 �, A o dower, Mass., a3 • COC M.C. WICK � ADRATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 02ot to Do BUILDING INSPECTOR THISCERTIFIES THAT.......... ............1AW....................................................................................................................... Foundation has permission to erect........................................ buildings on ..31 ...........:...:....... . ... ....W, .....0.40. ..... Rough • t0 be OCCUpled a 1. .. .................................................................................... Chimney provided that the person accepting this permit sh m every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST S ELECTRICAL INSPECTOR /t� �� Rough ....................................................................................... .......................... Service d. BUILDING INSPECTOR Final Occupancy Permite Required Occupy un � Rid tO q t�,7 Bildig GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE a Smoke Det. Date.. �. .b. ... . ,10RT1y °f4„a° 6. TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SCHUSE� This certifies that . . . r.`. . . . .Nt�.�C �` ` . . . . . . . . . . . . has permission for gas installation . . . .'e. . . . . . . . . . . . . . . . . in the buildings of . .P R %u .W.A �. `�. . . . . . . . . . . . . . . . . . at . 3 . .M�. .�. . . ... . . . . . . . . . . . . .. North dover, Mass. Fee. -� Lic. No.�.b� �. . . . . '.'.-0 02 L% �. A GASINSPECTOR Check# 83 4433 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS WrING (Type or print) Date ! 03 NORTH ANDOVER,MASSACHUSETTS c Building Locations 3 g �N S 7L— Permit# Amount$ a Owner's Name New❑ Renovation Replacement ❑ Plans Submitted ❑ o° U z>0w a 0 6 o fi �a° w w . G °o U EW•w a a 1 04 x E» o SUB-BASEM ENT BASEMENT ]ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (print or type) Cone: Certificate Installing Company Name �v ete, /'� I-C 4 2 G L Corp. Address 1 7 91 Partner. /U.e w 7v N N iq O frsSs' Business Telephone 716- 6 c/ 7 /O t ❑ Fim/Co. Name of Licensed Plumber or Gas Fittery /4?- INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ Ifyou have checked M,please indicate the type coverage by checking the appropriate box. Liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ er's Insuran Wai er: I am avfpre that the licensee does not have the Insurance coverage required by Chapter 142 ofthe s.Ge La s, d y i afore on this permit application waiv27,1@ ' ent. ChecSignature of or Owner's Agent Agent ❑ i hereby certi a all of the details and formation I have submitted(or entered)in a application are true and accurate to the best of my knowl ge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 2.ofthe General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title Plumber / &,F/ 3 City/Town Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) ❑ JOumeyman e Date. . . . . . . . . . . Of NORTH �ti TOWN OF NORTH ANDOVER O ° p PERMIT FOR PLUMBING �,SSACMUS� This certifies that . f.o-e rv- has permission to perform . . .`^'`.° `�. . . . . . . . . . . . . . . . . . . • • plumbing in the buildings of . .�. . !'� . . A. � Y• • at . . .`. . . . . . . . . . . .�. . . . . S . . . . . . . . . . . . . . . . Nort ;Andover, Mass. -5 . - Lc. NoJ.t?13.1. . . ,S:.D�oz z� M t "v Fee. . .I. PLUMBING�NSP*E*C*T*0`R Q .3 4 + q Check # i 5712 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DOfPLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS `G QRW 9 Date Name Building Location � /y � Owners � Permit# Amount 3 r) Type of Occupancy New rl Renovation Replacement ® Plans Submitted Yes ❑ No E] . FIXTURES w a >� z En �ci a H a a H CA 4 9 0 `� WLn A aWrAa A x a F StlMM R4SM YI' ISE R M l r 2M FID(R FLOQ2 4IH FLOQt 5'IH R M M Hfm 7RI RaR SIH FLOQt (PrInstallinnt,org type) v � ��- %T�4 G Check❑ Corp.one• Certificate Installing Company NameF, ® Address f 7 01 O [Jy Partner. /v e a 3 Srs Business Telephone 57- 7171 ® Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above 4, s,u,r"an e signature Owner Agent I hereby cert t all of the details and information I have submitted or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the M �achusetts State Plumbing C ad_ ter 14 f the General Laws. By Signature,of Licenseaum er Type of Plumbing License Title 110133 / 1 City/Town Licens'Num e'er Master ® Journeyman APPROVED(OFFICE USE ONLY