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HomeMy WebLinkAboutMiscellaneous - 35 BEACON HILL BOULEVARD 4/30/2018i l e Date,/p2 ... I.fo . ........... 11711 / TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ss� CHU C,0( This certifiesthat ......................... ....... .......................................... perform permission to perfo......... ...... .. "r. ..... ........... . .................................. plumbing.. buildings of .... o .. ....... p.p-LAAL. at . ........... R.A`.c� North Andover, Mass. FeeLic. NoSS:v . ..... ................................................................................. PLUMBING INSPECTOR Check# 0-3z) I i ih Y �N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE,,' -v. PERMIT I �� °� # � ��• ___V__ __.___-. _.--_ - JOBSiTEADDRESS� 3��l_V� J OWNER'SNAMELonwc, Zt'�l-Ip v" -Qe�co✓�-[�\ OWNER ADDRESS ;SAME - - -- } i`57�= air i7 - ' t TEL ;FAX t TYPE OR OCCUPANCY TYPE COMMERCIAL I !! EDUCATIONAL ' 1 RESIDENTIAL'-,; PRINT CLEARLY NEW: t _ RENOVATION: ( REPLACEMENT-! %!PLANS SUBMITTED: YES �= NO!,' 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 GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM -- DEDICATED WATER RECYCLE SYSTEM DISHWASHER - - - - ---- - - --- --- - - - -- -- DRINKING FOUNTAIN FOOD DISPOSER -- :- - -- -- - - FLOOR 1AREADRAIN 1. INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAW - SHOWER STALL -- -, - - _ _ --- - - — _ ----- SERVICE/MOPSINK TOILET �. URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER — ��n.re.e,c_�.�s»w,.,�.,.��msw�.r-�,axr-,•--, _— f INSURANCE COVERAGE: I have a current Nabi insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES;' -_,__i NO r .-_ _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i .,j OTHER TYPE OF INDEMNITY 4 BOND I -._n OWNEWS 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 AGENT SIGNATURE OF OWNER OR AGENT I hereby car* that all of the details and information I have submitted or entered regarding this 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 mill be i�CMwith all Pe 'vent ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Lavis. J f� PLUMBER'S NAME ,'GEORGE A. POUDRIER LICENSE # 15764 SIGNATORE JP t s CORPORATION- 4,' 3?50C -_ (PARTNERSHIP: COMPANY NAME FBest Yet Installations Inc_ W1 ADDRESSISpencer South Road CITY' Spencer STATE �� MA ' ZIP 101562 j T EL j 5088852378 _ FAX 15088852377 1. CELL i 5087893486 EMAIL ; byi@best etrnstallations.com �*I­sy V-e-c"d 61v-n4C,,11 I -312_S�J�� :�'_"'�4 reJ ' to R r 3- C r The Commonwealth of Massachusetts Department of Industrial Accidents 1. Congress Street, Suite 140 1 Boston, MA 02114-2017 Y www mass gov/dia V 'Workers' Compensation iinsurance Affidavit: Builders/Contractors/Elec TO BE FILED WITH THE PERMITTING AUTHORITY. Apolicant Information { Name (Business/Organization/Individual):BEST YET INSTALLATIONS INC. Address: 15 SOUTH SPENCER ROAD : . City/State/Zip: SPENCER, MA 01562 #: 508-885-2378 Are you an employer? Check the appropriate box: 3 12 1 am a employer with 12 employees (full and/or part-time).; Type of project (1 7. EJ New constr 2.a I am a sole proprietor or partnership and have no employees working for me in an ca aci y p ty. [No workers' comp. insurance 'required.] 8. Remodelin f 3.[:]l am ahomeowner doing all work myself. [No workers' comp. insurance required.] t 9. El Demolition 4.[]l am a homeowner and will be hiring contractors to cwnduct all work on m y property. I will 1 0 ❑ Building ad ensure that all contractors either have workers' compensation insurance or are sole 11.❑Electrical n proprietors with no employees. 5-F7ractors 1 am a general contractor and 1 have hired the�sub-contlisted on the attached sheet 12.E] plumbing n These sub contractors have employees and have workers' comp. insurance? 13.❑Roof repair 6.❑ We are a corporation and its officers have exercised their right of exemption'per MGL a 14. nOther PLUI 152, § 1(4), and we have no employees. (No workers': comp. insurance required.] Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating ttiey are doing all work and the» hire outside contractors must submit a new affidavi Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not thos employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. 1 am an employer that is providing worker's' compensation insurance for my employees. Below is the poli information. Insurance Company Name: TRAVELER'S INSURANCE AGENCY Policy # or Self -ins. Lie. #: 5F21506A Expiration Date: 02/11/201 s or additions s or additions i Ig such. have ail job site Job Site Address: - ���� � R City/State/Zip:iA , "IN� — 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 forme 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 DA for';insurance coverage verification. i I do hereby cert! and the pains and penalti ' erjury that the information provided above is true and' correct Sinature: i Date: o� —��' Phone #: 508-885 2378FI j t Official use only. Do not write in this area, to be completed by city or town offrciaL City or Town: Permit(License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5 6. -Other . Plumbing Inspector Contact Person: Phone # 5 ■ 2 LU"' M e e2 y4 ■' I ��\ �222�� z�. �� �2■�± a� �.�J� � 4© «/\t® ; /\^C LL ■° e .�■ . oft I L 0 Lu . > � .©wu � » @ w .- . � o■luoy§ . . �.»e & La 9 n 11.59 Thiscerhnes that.................................................................................................................... has permission to perform .............U` ' .........................:..................................................... plumb i in he ildings of . 7'`'`�.. �`' ................................................................ at .......................... G'.`...........1t; North Andover, Mass Fee6........... Lic. No.;�:. t..M.................................................................................. Date ... �.��.(�........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING PLUMBING INSPECTOR Check # '31,25 .• — jr TYPE OR PRINT CLEARLY iBr"O%or V/ IVVV t 4V vN Vu V1Q/g /'11 t 6.9%oAt @VIV 1 Vi\ A 1 W%It/t 1 1 V 1 1.1%1 1.01\III t VvmLoll w 11V1 \t\ CITY NORTH ANDOVER MA DATE PERMIT # JOBSITEADDRESS35 6e-4C0WR--2/ ,eZi,16 OWNER'SNAME6C9WVAq Z411Otfvlolre OWNER ADDRESS SAME TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL d RESIDENTIAL _ NEW:',—j j RENOVATION: ( ',. REPLACEMENT: PLANS SUBMITTED: YES ✓j NOE FIXTURES Z 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 GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ✓ NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L`!.! 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 1 AGENT 11 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 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 pro V ion of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. / PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MPF7 JP DV CORPORATION[]# PARTNERSHIPS* LLC['# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX 978-208-0540 CELL EMAIL tomhalloran@comcast.net �\v1 ib17g1�,� YU0, ZJ �)I,Avc�lL r "`w D V ate.... ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 17his certifies that...f1..':. ...................... ......... liras permission for gas installation ................................ in thebuildings of ............ .............................................. at .......... 113 .. 6 .......... North Andover, Mass. Fee -10A.= ..... Lic. No2l.h�� .... ..................................................................... GASINSPECTOR Check# 1 b466 F` L\- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - TPRINTR CLEARLY CITY NORTH ANDOVER MA DATE j©1L (1%S PERMIT # JOBSITE ADDRESS ,3 5-96f 60 v �� ��� �L�Q OWNER'S NAME&,o1w,+ 2411b/PU1;f-'Q OWNER ADDRESS SAME TEL FAX OCCUPANCY TYPE COMMERCIAL'[] EDUCATIONAL RESIDENTIAL? NEW: RENOVATIONN REPLACEMENT: PLANS SUBMITTED: YESE# NO:✓I APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES [v]O- NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY' ✓ OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the ,dassachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT j 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 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 pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. mil/� PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MPD MGF ] JPF i JGF[] LPGI CORPORATION# PARTNERSHIP# LLC # COMPANY NAME: T. HALLORAN PLUMBING ADDRESS 826 DALE ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX 978-208-0840 CELL 978-685-9504 EMAIL tomhalloran@comcast.net 4,1 P "k www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): THOMAS HALLORAN Address: 826 DALE ST, KinoTU it mnrlvrrn ..v. a i . . !-%1 ML.ItJ V L.1 1 Phone #: v a 0-000-=U4 Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts 4. ® I am a general contractor and I Department of IndustrialAccidents Pi Office of Investigations i4 1 Congress Street, Suite 100 These sub -contractors have Boston, IYIA 02114-2017 P "k www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): THOMAS HALLORAN Address: 826 DALE ST, KinoTU it mnrlvrrn ..v. a i . . !-%1 ML.ItJ V L.1 1 Phone #: v a 0-000-=U4 Are you an employer? Check the appropriate box: 1. ® I am a employer with 4. ® I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.' required.] 5. ® We are a corporation and its 3.0 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t C. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ® New construction 7. ® Remodeling S. ® Demolition 9. ® Building addition 10.® Electrical repairs or additions 11.® Plumbing repairs or additions 12.® Roof repairs 13.® Other ..., umst aisu un our me section uetow snowing their workers' compensation poliev information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicative 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 -contractors have employees, they must provide their workers' comp. policy number. 1 ant an employer that is providing workers' compensation insurance for any employees. Below is tire policy mid job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct, I" Phone #: 978-685-9504 - Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License O oto zaAd— Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Towa Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 3� Date..... ../.......... �................... OF NOR7H, Or • 1 `` ,•••�OO�tn TOWN OF NORTH ANDOVER a � 9 PERMIT FOR GAS INSTALLATION HU Bt49 This certifies that ...... ?....--c...... ?.�t'................................... j................... 12g has permission for gas installation .......:.d4....e�'1' �`'.k-.....,.. inthe buildings of`I............................................................................................................... at..3,.f�...^...f���G.��l �f................................... NWNPECTO; t Andover, Mass. Fee .�1...cnl... Lic. No.�'?,. a�..�. AS Check #�� 10143 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE �jPERMIT# JOBSITE ADDRESS `rGy� OWNER'S NAME �p•,.� c� GOWNER ADDRESS 79—s -_ KA =TEFAX - - TYPE OR OCCUPANCYTYPE COMMERCIAL[] EDUCATIONAL® �RESIDENTIAL CLEARLY NEVk . RENOVATION: D REPLACEMENT: 0 PLANS SUBMITTED: YES Q NO APPLIANCES 7 FLOORS- BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER [ FIREPLACE _ FRYOLATOR FURNACE GENERATOR _ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT (� OVEN [— POOL HEATER ROOM 1 SPACE HEATER ROOFTOP UNIT f UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL, Ch. 142 YES WNO I IF YOU CHECKED YES, PLEASE INDICATE THE F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY L] BOND R OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 942 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E-11 AGENT D 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 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 co r nee with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # `Z,2 -?i SIGNATURE MP [J MGF LjI JP ® JGF LPGI CORPORATION Q# L= PARTNERSHIP 0#= LLC E]# COMPANY NAME: 61t v --t j �� -�- ADDRESS12.,q�' CITY 1 t _ _ _ _ �� STATE ZIP O 1 TEL FAX CELLEMAIL H z� 0 H�U F4 � z� Occ y� W j ~ W a E-1 u w 4* F- W ~ � 7 a w WW �- U) aLLI a O W w C/3 a a a a a n(400i U J E. a CL Q car . Eli 2 w F- LL W H O z 0 _ H U W UD C�7 Up"' The Commonwealth of Massachusetts Department of IndustrialAceidents ''~= f I Congress Street, Suite 100 =: F Boston, MA 02114-2017 www.mass.gov/dia �M syr I tion Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. Wo><kers Compensa TO BE FILED WITH THE PERMITTING AUTAORITX. Please .A,pphcant Information ., Print Leeibly Name (Business/Ocganizationllndividual): �j % �1� e YI n 1 S Address: 2 g ��''' ``� `'� r k CitylState/Zip:= Are you an employer? the appropriate box: Phone 1.0 I am a employer with employees (full and/or Part-time)'* 21�jfll am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 6.0 We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, § 1(4), and We have no empldyees: [No workers' comp. insurance required] Type of project ()required): 7. ❑ New'constructlon 8. Remodeling 9. Q Demolition 10 0 Building addition 11.0 Electrical repairs or additions 12. W Plumbing repairs or additions 13•. [ I Roof repairs 14.0 Other *Any applicant that check's bot #1 must also fill out the section below showing their workers' compensation policy information. homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entit{es, have employees. If the sub contractors have employees, they must provide their workers' comp. policy number. ensation insurance for my employees. Below is the policy and job site I am an employer that is providing -workers' comp information. Insurance Company Policy # or Self -ins. Lic. ExpirationDate,. City/State/Zip: Job Site Address: 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. Ido hereby certify under the pains and penalties ofperjury that the information provided bo is true and correct. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their erriploy-ees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of We, 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"dr trustee of an individual, partnership, association or other legal entity, employing emplbyees: • 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 rIequired." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpubli-c work until acceptable evidence of compliance with the insurance requirements ofthis 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) namc(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 anLLC 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' compensation 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 (ifnecessary) 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The 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 A 2351 Date ....... HORTI{ ` , TOWN OF NORTH ANDOVER oto 0-0 p PERMIT FOR WIRING This certifies that ... ...... CG../�.... has permission to perform ....� '' r1..s..: ?.......<..�� "5 �0� ff!'/ S wiring in the building of ......7. C1. ........................................... at .....1.. 5.......�. ........J ............... . North /Anndove> j Aass. Fee ... S i� C)v �...... . ... .'�? ......1../�......... .................. Li c. No. ELECTRICAL fAspEcTOR Check # _1�L WHITE: Applicant CANARY: Building Dept. PINK: Treasurer J A Rough !rt Service Final t'14C Vammnnwcbtth of A8,6 8141 actio Office UseOnly Department of Public Safety Permit No. BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Occupancy & tee Checked 3190 (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) City or Town of U A t I/V 0 V �r The undersigned. applies for a permit to perform the electrics Location (Street & Number) Owner or Tenant /IeTeP below. fzt atvo, Owner's Address !5 AC On/ Lam' Is this permit in conjunction with a building permit: Yes LJ No Purpose of Building -- —_. -- Existing Service _ 60 0 ..— Amps _ //'Z/�,1 Volts A New Service —/00 /Z 0_Amps _/ 2 V Volts Date zoo[) .. //To the Inspector of Wiresr (Check Appropriate Box) Allity Authorization No. nD 3 6 q y Overhead�jW/� Undgrd ❑ No. of Meters Overhead LJ Undgrd ❑ No. of Meters / Number of Feeders and Ampacity _. /n��t /n�,^, r �/, p -y7� a Location and Nature of Proposed Electrical Work V�6hAyAe Jery1(C /U lgomo AITTAI� J �aQry Q �ZdyoLT NT��%S OTHER: ;�-v' WiNOW �//' Co 1plTio fs ANO INSURANCE COVERAGE: Pursuant to the requirements of Massachusees General Laws 1 have a current liability Insurp�ce Policy including Completed Operations Coverage or its substantial equivalent. YES NO 1711 have submitted valid proof of same to this office. YES IVNO 1.1 If you have checked YES, please indicate the type of coverage by checking the appropriate box. ,1 INSURANCE J BOND F1OTHER❑ (Please Specify) E� WL / xpiration Date) Estimated Value of Electrical Work $ Work to Start 1hoInspection Date Requested: Rough Final //// I t C, Signed under the naltie of perjury: FIRM NAME T. S -r A �1ef(y LIC. NO. �� Licensee hAfAI T'ST•f71V Signature. ---- _LIC. NO.sl"e Address O-� AVe. /r/eIm/ Bus. Tel. Nol�/ 7�S Tr J Alt. Tel. No. JyWe OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) (Signature of Owner or Agent) Telephone PERMIT FEE S TOTAL No. of Lighting.Outlets No. of Hot Tubs No. of Transformers KVA of Li htin Fixtures Above In, Swimmin Pool rnd. [:]rnd. Generators KVA Emergency Lig hog No. of Receptacle Outlets 7 No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners EIRE ALARMS No. of Zones No. of Detection and Ota No. of Ranges No. of Air Conditioners Tons Initiating Devices of Sounding Devices No. of Self Contained Detedlon/Srnmding Devices Municipal localConnection ❑Other No. of Dis rsals eat Total TotalNo. No. of Pumps Tons KW No. of Dishwashers S acetArea I leatin KW No. of Dryers f featin Devices KW No. of Water Ifealers KW n. n o. o Signs Ballasts ow n t, ge Wiring No Ifydro Massage Tubs No. of Motors Total IIP OTHER: ;�-v' WiNOW �//' Co 1plTio fs ANO INSURANCE COVERAGE: Pursuant to the requirements of Massachusees General Laws 1 have a current liability Insurp�ce Policy including Completed Operations Coverage or its substantial equivalent. YES NO 1711 have submitted valid proof of same to this office. YES IVNO 1.1 If you have checked YES, please indicate the type of coverage by checking the appropriate box. ,1 INSURANCE J BOND F1OTHER❑ (Please Specify) E� WL / xpiration Date) Estimated Value of Electrical Work $ Work to Start 1hoInspection Date Requested: Rough Final //// I t C, Signed under the naltie of perjury: FIRM NAME T. S -r A �1ef(y LIC. NO. �� Licensee hAfAI T'ST•f71V Signature. ---- _LIC. NO.sl"e Address O-� AVe. /r/eIm/ Bus. Tel. Nol�/ 7�S Tr J Alt. Tel. No. JyWe OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) (Signature of Owner or Agent) Telephone PERMIT FEE S Location No. y % Date NORTH TOWN OF NORTH ANDOVER �.... . • 0. Cr Certificate of Occupancy $ �- + ; Building/Frame Permit Fee $ "° SASE CMU< Foundation Permit Fee $ Other Permit Fee $ / - U ° Sewer Connection Fee $ Water Connection Fee $ �— TOTAL $ ` : d O Building`Inspector �/9f41 ala I� 15 - OD PAID ►er g 065 a Div. Public Works PER.Iq NO -'r APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. /PAGE 1 MAP 4J0. LOT NO. I 2 RECORD OF OWNERSHIP iDATE BOOK PAGE i ZONE SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING (3 �J \� OWNER'S NAMEa , NO. OF STORIES SIZE OWNER'S ADDRESS,2,,,e �•1 + BASEMENT OR SLAB ARCHITECT'S NAME � SIZE OF FLOOR TIMBERSc� 1SQT _ ,2N0 3RD ^mac BUILDER'S NAMEKj� -C --'C eE-� SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET j POSTS D,,S= FROM�LiOI LI i E5,y¢IDES � REAR �q a 1 "' " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION �•1�Y AL \�P `THICKNE�SS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION `f C J MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND ��\1 L WILL BUILDING CONFORM TO REQUIREMENTS OF CODE •�{{ IS BUILDING CONNECTED TO TOWN WATER r BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER ��✓ ei IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED PERMIT GRANTED / ru OWNER TEL. # r CONTR. TEL #IR � CONTR. LIC. # 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST �1� ZZ EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD i OCCUPANCY 12 SINGLE FAMILY S-ORIES MULTI. FAMILY OFFICES APARTMENTS _ CONSTRUCTION 2 FOUNDATION CONCRETE 8 INTERIOR d PINE HARDw D— PLASTER FINISH I 2 I3 — CONCRETE BL K. BRICK OR STONE PIERS DRY WALL UNFIN — — 3 BASEMENT AREA FULL FIN. B M T AREA '/. 'h 3/. IN. ATTIC AREA _ NO B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B _ 1 ��_ 2 3 _ DROP SIDING WOOD SHINGLES ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ _ CONCRETE EARTH HARD,,) D COMMON ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY BRICK ON FRAME ATTIC STIRS. B FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE GAMBREL FLAT HIP BATH (3 FIX.) MANSARD TOILET RM. (2 FIX.) 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 _ 7s, 13rd ELECTRIC NO HEATING i THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. I a Ff`1 i i r L I � l U m z m m C-) O z ' IO M m D 0 z CL1 CO) C7 CD n Z y CD O 'O CL r �• CL �• y O v CD CDCL O r CD CD O CD W C CDCD y S: y O I cc CD C) CO)CD O CD Z oCC) 0 C CD O C_ O 0 Z CD N 0 _ cc 0 C d CD to S. * O y C O o: y H CCD I?��d x _. y O CS y < CD 'o y C'O CD n CD 0 M C4 CD �C S =o CO = CV w c T m aim �_ rn O CD CA O x �'y � a .0 O .0.. O ZC C) C) y O CD � y 'O . y�o C= •r..' CD � CSD co y 0 CD CL H 1 D7 y =M -Q O. CD C dD: < y CD CO2 C `CD _ CD CD O O CD ?D Otl 7 O moo: CD CD co Ab ..r O � dd: _:2 ate. n O� c o _ � cv A zk 0 , t I� Cf) D ror cf)�� rD z UQ �,�z��P� m < F z m Y m c 7' C) °'_ z c m G o' C C/) rt 'O CA � C z C-) O z ' IO M m D 0 z CL1 CO) C7 CD n Z y CD O 'O CL r �• CL �• y O v CD CDCL O r CD CD O CD W C CDCD y S: y O I cc CD C) CO)CD O CD Z oCC) 0 C CD O C_ O 0 Z CD N 0 _ cc 0 C d CD to S. * O y C O o: y H CCD I?��d x _. y O CS y < CD 'o y C'O CD n CD 0 M C4 CD �C S =o CO = CV w c T m aim �_ rn O CD CA O x �'y � a .0 O .0.. O ZC C) C) y O CD � y 'O . y�o C= •r..' CD � CSD co y 0 CD CL H 1 D7 y =M -Q O. CD C dD: < y CD CO2 C `CD _ CD CD O O CD ?D Otl 7 O moo: CD CD co Ab ..r O � dd: _:2 ate. n O� c o _ � cv A zk 0 , t I� Cf) D ror cf)�� rD z UQ �,�z��P� m < F z 7Qm :71C• m Y m c 7' C) °'_ c m G o' C C/) rt 'O al p z z aa 0 c Date... 7 �l. " �.. . F "ORTM TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9 ' �9SSACHU?' .r. This certifies that . r".......... has permission for gaminstallation .1 ............ in the buildings of 7 ! . ! ................ at,555 . ........ orth Andover, Mass. Fee!;;?16 ..0. Lic. No. y/ , -.: 3 . .......................... r. GAS INSPECTOR t `Check # __W,/V 4 4724 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or / Mass. Date 49h �! Z�p��� Permit # �� Bulding tion / / ers Narrye / G• Type of Occupancy f? E51 7CN Ti r3 e r G New p Renovation ❑ 21" Plans Submitted: Yesp No p Installing Company Name j;rk=a T A .1m ma T r1 H2O Check one: Certificate Address 31 t2ba c H ;n A ry -af. . ❑ Corporation M E T H U E 1J 01 ra U 1 ❑ Partnership Business Telephone /,o 92 -179 -7 f 2-Firm/Co. Name of Licensed Plumber or Gas Fitter " ojmr-T 8 - 8mm fa 1 AJ?o l INSURANCE CO`.'Elt.-"GE: I have a current pi' bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. 11 Yes EY No ❑ W "you have checked Yes, please Indicate the type coverage by checking the appropriate box A'eiability Insurance policy ET." 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 aca rate to the best of my knowledge and that all plumbing work and installations performed under the pe i ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. By T of License: C� Plumber n ure of Ficensed PlumWor Gas Fitter 9ter er License Number 4333 Journeyman z 0 F- 0 W N z_ J Q z_ LL W W L O Z H t - u 4 J o Z O O G W V1 O O � �• W. V � O O Z a p O W W 3 Z c 0 J H W � ID V J I d � AL Q W W W N W S L!, HI W Y N z 0 F- 0 W N z_ J Q z_ LL W W L Location No. ��% Date y /0 NORT►, TOWN OF NORTH ANDOVER L O 9 t ; + ; , Certificate of Occupancy $ . 11 bwwTo �•�{� CMustt Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # -,� (J Building ln, ector 14ORTH O t,. ao ,•'EyO O _. S TOWN OF NORTH ANDOVER APPLIGITION FOR PL.,kN, EXAMINATION i%s3^CNUSE Permit NO: 01 Date Received: 7 -/P -(AZ Date Issued: -f -%Q-4,6 EMPORTANT: Applicant illust complete all itcllls oil this LOC'ATION3_Z_1J4 4 r -O 1'rinl PROPERTYOWNER QQ Print tL1PNO.: O�S?-&ARCEL: �% ZONING DISTRICT: TYPE AND USE OF RUI1.nING HICTnD14- nIC MW9r X; Po n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential -: New Building i Addition_ i Alteration i I -One family Two or more family No. of units: E Industrial I I ✓tcpair, replacement Demolition = Assessory Bldg — ------ — L..' Commercial Moving (relocation) -' Other _. Others: Foundation only r»✓ k -1%1r J JUIN Ur wUK& 1 V til✓ FKtt' VKMt 1) J,dentification Please Tyne or Print Clearly) O\VNER: Name- Z -,z)4 1 \Lo Phone: 6 6/9 Signatur� Address: ( tQ f r CONTRACTOR Name:((Aah tot) PhontcM LfIie ;address: I`� � �l(.i l tl.J Sr, ���tL M� 0� �� Supervisor's Construction License: Exp. Date: l� { Tonle lmpru\ rnlcnt License: J01. IrSl� Exp. Dalc: \RCM l hC'T l N(il �F:I :IZ Name: Phone: kddress: Reg. No. FEE SCHEDULE: B1 LDLVG PERMIT: 310.60 PER SI000.00 OF THE TOTAL ESTIdL-I TED COST BA,.4ED OA SI?5.00 PER S.F. Total Project Cost :$ —?, 3s -o x10.00 FEES �7• � Check No.;,--.. T-1-NA b -\-/\ No.: /9ylH �• 0 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits :j Building Permit Application ❑ Debris Removal Form J Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And,'Or C.S.L. Licenses Li Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks ❑ Building Permit Application ❑ Form U ❑ Surveyed Plot Plan ❑ Debris Removal Form ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (1f Applicable) u Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Pen -nit Application ❑ Form U ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses Workers Comp Affidavit a Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Copy of Contract Mass check Energy Compliance Report In all cases if a iariance or special permit was required the To%%n Clerks office in list stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One cope and proof of recording must be submitted w ith the building application Doe: 1\SPE(" I10N.11. Sr:R% K ES DF.PAR'rNus'N r:BrFQR%i,)5 TYPE OF SE\\ \RGE DISPOSAL g,�tilassa�ge Body ,art S"�imnlin� Pools Tannin Public Sewer Tobacco Sales — I Fobd ackgiri,.Sales \Veil i Permanent Dempster on Site I I 1 Prig ate (septic tank, etc. i NOTE: Pervtms confraefing K • 1 « nregiwerer! eown chrrc Ju not have (teee.vv to the r naran(r./nnt! Signature. of;�gent!0\V11er �.�z --- Signature of Contractor-- Plans Submitted _+ Plans Waived Ell Certified Plot Plan -_. Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Zoning Board of :Appeals: Variance, Petition No: Z.onine Decision.ri•.ccipt submitted yes DATE REJECTED DATE APPROVED F-1 11 ❑Water Shed Special Permit %-j Site Plan Special Permit F1 Other DATE. REJECTED DATE APPROVED ,J DATE REJECTED I'lanninu, Board Decision:-----_--------Conunents Conservation DLxislon:_ _COn1nlCnts DATE APPROVED \V ater a, Sewcr connection signature b: date Temp Dunlptitcr on site yes— no_ Fire Department :;i,nattn-e'date —------------=�� "O� Building. Permit ,%pproved and Issued by: ' Buildina Setback (ft.) [----Front Ward j Side Yard Rear Yard RcqLfircd Provided j Recluircd_1 Provides Rcquircd Provided DIMENSION N uniber of Stories:------ Total square teet of floor area. based on Fxtcrior dimensions._ Totalland area. sq. 1"! 1 1 d I 'J 1 ;!:11 Pettis Construction 714 South Main St Bradford MA 01835 978-374-9240 978-373-9369 FAX ESTIMATE Donna Zahorviko 35 Beacon Hill Blvd North Andover MA 01845 March 24, 2006 978-686-1917 After inspection of roof area, we make the following recommendations: MAIN ROOF & SIDE ENTRY - STRIP & RE -ROOF Strip areas to deck, inspect deck, re -nail as necessary Replacement of rotted, or damaged decking as necessary, time and stock extra Apply 6' ice and water, eaves of roof and valleys Cut in new lead flashing into chimney Apply 15 Ib roofing felt to balance of roof Install custom -formed .024 aluminum drip edge Install IKO Aristocrat or equal 25 year warranty MATERIAL & LABOR $6,750 NOTE: Stripping old roofing will cause a great deal of deteriorated roofing to fall between spacing of roof boards, it is our strong recommendation to have owner cover and protect articles in areas below roof. Articles/materials inside the home are the responsibility of the homeowner. Pettis Construction is ndt liable for any damages incurred to articles/materials within the home, We recommend keeping windows closed and window fans and air conditioning units off during roof stripping. It is advisable to take down any article that may fall off walls or shelving during the roof procedure. A shingle over style ridge vent should be installed to increase air flow $400 Clean and haul all roof debris Permit by Contractor Certificate of Insurance upon request Workmanship guaranteed 5 years NOTE: Remove gutter front & back entry. After roof is complete, re -install gutter over drip edge and Ice & Water system. MATERIAL & LABOR $240 All material is guaranteed to be as specified. All work to be completed in a workmanship like manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All agreements contingent upon, strikes, accidents or delays, beyond our control. Owner to carry fire, tomado, and other necessary insurance. Our workers are fully covered by Workman's Compensation insurance. We propose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of the above outlines. Payment to be made as follows: 1/3 at job start, balance upon completion. All other arrangements by prior agreement only. NOTE: This proposal may be withdrawn by Pettis Construction if not accepted with 30 days. Acceptance of Proposal—The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specked. Payment will be made as outlined above. 7 Date of Acceptance: ai/,P/, �, Sianature m m m m y m y v m v, C � d CD az y CL o �, � � o d = H O o v CD CD o CL Q: d CD co 0 CD 00 00 G CD y CD CD �O y � O C2 CO) O z St O CD O CD 0 n•. I C O C2:-% O w --4 0 ao 5.m y CL o CD Cl) mm06 m h ,y 0to R. m O 71 Bagel � m CO O O O CO) -� IE C m. m a = w : -� CD � m O N A -.m o. m 3 Ute: IE N o: co O ES -"o o 0m: moo: CD a� o_ W d Im _.0 nom: " 5 ro s�tipp fD O F �� 071 b 'rf �j ?�. O � W)71 ?�.. O Cli � w O I N 0 GQ O z N O Q.. a v 0 0 0 c s ti ✓!ze 61riraoo��nrail/a o�✓aaoac/u�ael7a BOARD OF BUILDING REGULATIONS i License. CONSTRUCTION SUPERVISOR t Number, : CS, 017654 tt _ s � Birthda3e fl8T13/1948 Expires 0`$/13/2007 Tr. no::1930;0 714 S MAIN ST 4 BRADFORD, MA 01835 Commissioner- Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR, Registration: 101556 a -T\ pn 6/2612006. 1 jType Ra�tnership PETTIS PARTI SRS, i —• ' — f. - John Pettis, Jr.'� 714 S. Main 1 Bradford, MA 0183 Adm mstrWt. 2 __-