HomeMy WebLinkAboutMiscellaneous - 366 CANDLESTICK ROAD 4/30/2018 (2)Date..... ..................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that//
.... . ............................................... 1
��/ ...................................
has permission for gas installation .............14 —,e /y/4 ---,—
in the buildings of ,
I
at.,3Cv..o ............. .................
................. North Andover, Mass.
Fee.
.a......l-)..... .....—
..... Lic. No..12-..'.',� .... ... . ...................................................
GASINSPECTOR
Check# 640/1
9712
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING
WORK
u�
CITY /!�< �i1i�tE'rL- MA DATE�G� %`� PERMIT#
JOBSITE ADDRESS 66P J�9 h-5-7161, 10 OWNER'S NAME
GOWNER
ADDRESS TEL /-160/-, Wl FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARLY
NEW:. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS— BSM 1 2 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 / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER K
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES V(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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
C
SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true nd ccurate to the best of my k owl ge
and that all plumbing work and installations performed under the permit issued for this application will be in comp
an with all Pertinent vision o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE
MP X MGF JP JGF LPGI CORPORATION# 3631 C PARTNERSHIP # LLC: #
COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3
CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224
FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com-) V
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y The Commonwealth of Massachusetts
--- Department of Industrial Accidents
,f r
f Office of Investigations
t 600 Washington Street
Boston, i1M 02111
'4 www.mass.gov/tlia
Workers' Compensation Insurance Affidavit: Builders/Cont>ractors/E9ectricia>ns/Plurnbe>rs
,imlicant Information Please Print Leaibl'
Name (Business/Organization/Individual):
Address:��
/State/Zip: , ;�'Ir�� ✓�';�%
X/ Phone #:
Are you an employer? Check the appropriate box:
l.X I am a employer with 2 �
4. ❑ I am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for mein any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.]
c. 152, §1(4), and we have no
employees. [No workers'
insurance
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or- additions
l I. E] Plumbing repairs or additions
12.❑ Roof repa' Aw l3 Other
*Any applicant that checks box #I1 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 entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. a _.
Insurance Company Name:
Policy # or Self -ins. Lic. #: r�I — e���.�1% Expiration Date: %%3 amici
Job Site Address: D �� r�/� City/State/Zip: z
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 STOP WORT{ 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.
1' do hereby cerVy dnd§,r the
that the information provided above i true and correct.
Phone #: 971-5- a 11114eji/'
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building (Department 3. City/ 'own Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: ____ Phone #: 11
.... Commonwealth of Massachusetts
Department of Public Safety
Hoisting Engineer
License: HE -110323
PETER G VIENS` '
9 BLUEBIRD LIQ
;uj
ATKINSON NIY 03 '✓t L
I ,
Z/..-� �� I f a9
'"er Expiration:
Commissioner 11/13/2015
State of"'e i,Hampshire
GAS FITTERS`SLtE'I� E
NAME: PETER I NS --L `
ENDORSEMENTS. 1P
DATE ISSUED: 10/1.5/2013
DATE EXPIRES: 11/30/2015
LICENSE #:GFE0700587
I certify that I have examined
In accordance with the Federa o or darner Safety ul ions (49 391.41-391.49) and with knowledge
of the driving duties, I find this person is qualified; and, if applicable, only when:
❑ wearing corrective lenses ❑ driving within an exempt intracity zone (49 CFR 391.62)
❑ wearing hearing aid ❑ accompanied by a Skill Performance Evaluation Certificate (SPE)
❑ accompanied by a ❑ qualified by operation of 49 CFR 391.64
waiver/exemption
The information I have provided regarding this physical examination is true and complete. A complete examination
form with any attachment embodies my findings completely and correctly, and is on file in my office.
SIGNATURE OF MEDICAL EXAMINER
TALEPHO E _
01
DATE
L
ME AL EXAMINER'S NAME (PRINT)
❑ MD ❑Chiropractor
[]DO Advanced
Practice Nurse
MEDICAL EXAMINER'S LICENSE OR CERTIFICATE NO.
ISSUING STATE
/r
❑ Physician ❑ Other
Assistant Practitioner
NATIONAL REGISTRY NO.
SIGNATOR OF IVER�
INTRASTATE
CDL
ONLY
❑ YES NO
❑ YES NO
DRIVER'S LICENSE NO.
STATE
/1 vs /0
ADDRESS OF DRIVER
9 1'3hJ b4
MEDICAL CERTIFICATION EXPIRATION DAT
PLY 1 DRIVER PLY 2 MOTOR CARRIER 26520 (5/13)
IPA1
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
Commonwealth of Massachusetts
Department of Public Safety
Pipefitter Journeyman
License: PJ -028388
PETER G VIENS
9 BLUEBIRD LN^R `
ATKINSON NH�03811 Sl " "`
t��
`` Expiration:
Commissioner 11/13/2015
j STATE OF NEW HAMPSHIRE
BUREAU OF BUILDING SAFETY & CONSTRUCTION
PLUMBING SAFETY SECTION
I NAME: PETER G VIENS
I
F LIC #: 3249 M
EXPIRES: 11/30/2014
w MASTER
ET
Peter Viens
Cert # 1023121001-12
Expires: 10/23/2015
Certification
N.F.P.A.99-2012 ed.
i ASSE 6010 Installer & ASME IX Brazer
OSHA 6003.6337
�i
I
j U.S. Department of Labor
Occupational Safety and Health Administration
Peter Viens
j has successfully completed a 30 -hour Occupational Safety and Health
i! Training Course in
i Construction Safety & Health
t
I
(TaWr -1e /2
This certifies that. ,l�.A. f �� ... /�/ �� ............. . .
has permission for gas installation .................
in the buildings of. . _/ ....n ........................
at .. _ ..,;I! .. !:�,.L�Q.�,�, -•,��, .� rel... , North Andove , Mass.
Fee3o.S'�... Lic. No. %/y?� ... ... ....... .. .
GAS INSPECTOR')
Check #
8569 ��
CI
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01
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
...:. _ o
CITY'MA DATE I �-��' PERMIT #
JOBSITE ADDRESS C, / C WOWNER'S NAME "�El
GOWNER
6&—
ADDRESS TEL FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY
NEW: ❑ RENOVATION: ❑ REPLACEMENT:/ (� PLANS SUBMITTED: YES ❑ NO E]APPLIANCES
-1 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 /SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X 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
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 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 fiance with all Perti npr vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Michael H. House LICENSE # 7173 SI NTR
MP d❑ MGF ® JP ❑ JGF ❑ LPGI ❑ CORPORATION &a # 3377C PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME MERRIMACK VALLEY CORP. ADDRESS 15 AEGEAN DRIVE, UNIT #3
CITY METHUEN STATE MA ZIP 01844 TEL 978-689-0224
FAX 978-689-2206 CELL 978-815-4523 EMAIL
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daftk The Commonwealth of Massachusetts
Department of IndushialF Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print LegiblyName (Business/organization/Individual): fndividual) : .
Address:
A
City/State/Zip:
Phone#:_ 978-9rc�
Are you an employer? Checkthe ropriate box:
1I am an employer with 4.0
_
employees (full and/or part time).*
I am a general contractor and I
have hired the sub -contractors
2.0 I am a sole proprietor or partner-
ship and have no employees
listed on the attached sheet.
working for me in any capacity.
These sub -contractors have
employees and have workers'
[No workers' comp. insurancerequired]
comp. insurance. $
3. I� I am a homeowner doing all work
5.0 We are a corporation and its
officers have exercised their
myself [No workers' comp,
insurance required] t
right of exemption perm MGL
C. 152, § 1(4), and we have no
employees. [no workers'
comp. insurance required.]
Type of Project (requu
6. 0 New construction
7. 0 Remodeling
8. 11 Demolition
9. C Building addition
10. 0 Electrical repairs or additions
11. 0 Plumbing repairs or additions
12. G Roof repairs
13.4VOther.iQ
*Ray applicant that checks box #1 mast also !i0 oat the section blow shy % ��'�/���/tl�
tHomeowners who submit this affidavit in their workers compensation policy mformatioa
indicating they are doing an work and then hire outside Contractors must submit a new
$Coatactors that check this box mast attach an additional sheet showing the name of the sub-Contradors and state whether or not�o entities have employees if
the sub -contractors have ees. theymost rovide their workers' co polky
I am an employer that is r n��`
p oviding workers compensation insurance or
information, f my employees. Below is the policy anis job site
Insurance Company Name: ` 7
.c /
Policy # or Self -ins. Lic. #: � j �' � �
` Expiration Date:
Job Site Address: _/eel
City/State/Zip:/#V I��G�,�'���
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 152 can lead to the imposition of criminal
up to $1,500.00 and/or one year imprisonment as well as civilorm GORDER
fi a fine
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office o Investigationsne of
of the
DIA for coverage verification.
I do herby
Print
official use only
�e
that the
above is true and correct.
Do not write in this area to be completed by �cio or town official
City or Town:
Permit/license #:
Issuing Authority (circle one):
1.Board of Reath 2. Building Department 3. City/Tow. Clerk 4. Electrical Inspector 5. Plumbing In
6. Other Spector
Contact person:
Phone #:
May 07 12 02:27p Mike House 2079658719
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..<°`�.... ! ."'.f.. k12
has permission to perform ......
. .�.�/..
plumbing in the buildings of ... ............ ............... .
at ....? �� ( .... i ...,�/`�... �'C. .. � _.
:: , North Andover, Mass.
Fee. 4.. ". Lic. No..,'..' //._.............. .
PLUMBING INSPECTOR
Check # -,) N n
8564
4
Date
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..<°`�.... ! ."'.f.. k12
has permission to perform ......
. .�.�/..
plumbing in the buildings of ... ............ ............... .
at ....? �� ( .... i ...,�/`�... �'C. .. � _.
:: , North Andover, Mass.
Fee. 4.. ". Lic. No..,'..' //._.............. .
PLUMBING INSPECTOR
Check # -,) N n
8564
°\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town. O 1r 9.-r- PAA. Date: Permit#
Building Location21ry6 Cgtti�Owners Name,%V��O�
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement:; Pians Submitted: Yes ❑ No Q
V--tint,T -),4 -\-)% w;�s, —isOro \ FIYTIIPFR
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ® No ❑
If you have checked Y� please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 54 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 ❑ Agent ❑
Sionature of Owner or Owner's Aeent
I hereby certify that all of the details and information I have submitted for entered) reuardinci this aoolication 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
Title ® Plumber Signature NLicensed Plumber
® Master q 2�
City/Town ❑Journeyman License Number:
,\ OFFICE USE ONLY'
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Check One Only Certificate #
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❑ Firm/Company
Name of Licensed Plumber: "tvt�+Ltr icV � '-A\A% l
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ® No ❑
If you have checked Y� please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 54 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 ❑ Agent ❑
Sionature of Owner or Owner's Aeent
I hereby certify that all of the details and information I have submitted for entered) reuardinci this aoolication 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By Type of License:
Title ® Plumber Signature NLicensed Plumber
® Master q 2�
City/Town ❑Journeyman License Number:
,\ OFFICE USE ONLY'
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TOWN OF NORTH ANDOVER
: PERMIT FOR GAS INSTALLATION
This certifies that �..I/S.. .
has permission for gas installation ..!. {�?... �f
in the buildings of .......................
at ..�m � {l. S S �... .... , North Andover, Mass.
7�e. d.. l
Fee �(! .� �.. Lic. No. � .. .....0.. ��.�- .:............. .
GAS INSPECTOR
Check # _ 7
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
i
Cityaown).�)otNn �r� oV e.•t , MA. Date:%i !o Permit#
Building LocationCc C,atn Q.S�1C k �tl Owners Name\h
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Fk] Plans Submitted: Yes ❑ No
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Check One Only Certificate #
Installing Company Name
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City/Town�
❑ Partnership
Business Tel: COIN 'Act "k i Fax: ❑ Firm/Company
Name of Licensed Plumber/Gas Fitter: r%` LIT tt� -4XI �'+
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No El
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 9 Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 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 ❑
Si nature of Owner or Owner's Agent
By checking this box ; 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title
)e of License:
Plumber
Gas Fitter
Master
own n LP Installer
Signature of L*ensed Plumber/Gas Fitter
License Number: \ �0' 4"zc
Date. �- I/Ox .7
TOWN OF NORTH ANDOVER
o PERMIT FORUMBING
This certifies that ...<1� %6��
........................
has permission to perform .... . �!'�-' ........................
plumbing in the buildings of ...4k �f i . 2 ....................
at ... 3 G !� . <7�� �^ " s {' ` ......... , North Andover, Mass.
Fee. .3. Lic. No..�
PLUMBING INSP CTOR
Check #
7250
MASSACHUSETTS UNIFORM APPLICATION FOR.PERMIT TO DO PLUMBING
(Print Ae
/�
ate 20 d Permit # 2)�J
Building L catio r
er's ame v
Type of Occupancy
New ❑ Renovation ❑ Replacement" Plans Submitted: Yes ❑ No ❑
nstalling Company Name
Odd
1
flame of Licensed Plumber or Gas Fitter
FIXTURES
70M�0
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S.P. #
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1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH .FLOOR
7TH FLOOR
8TH FLOOR
nstalling Company Name
Odd
1
flame of Licensed Plumber or Gas Fitter
0101- ong: Certificate
❑ Corporation
❑ Partnership
�.,bP,<rm/Co.
irv�ur[ArvGt c�UVERAGE:
I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142.
Yes Y/ No.O
If you have checked Yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy P_1__ Other type of indemnitv n P- a n
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent O
iereby certify that all of the details and information I have sub mltted entered) In above -application are true and accurate to the best of
y knowledge and that all plumbing work and installations performed Vndyr the permit iss for this application will be in compliance with
I pertinent provisions of the Massachusetts State Plumbing Code a tfjg142 ofjthe ural Laws. _
FBy - �7itle
ity/Town i
APPROVED (OFFICE USE ONLY)
ure of Licensed lumber
Type of License: b aster ❑Journeyman
License Number__ g ��
70M�0
IMMIM
IMMIN�
lw��M
1110000
Wm
0101- ong: Certificate
❑ Corporation
❑ Partnership
�.,bP,<rm/Co.
irv�ur[ArvGt c�UVERAGE:
I have a current liability insurance policy or Its substantial equivalent, which meets the requirements of MGLCh. 142.
Yes Y/ No.O
If you have checked Yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy P_1__ Other type of indemnitv n P- a n
OWNER'S INSURNACE 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.
Signature of Owner or Owner's Agent
Check one:
Owner ❑ Agent O
iereby certify that all of the details and information I have sub mltted entered) In above -application are true and accurate to the best of
y knowledge and that all plumbing work and installations performed Vndyr the permit iss for this application will be in compliance with
I pertinent provisions of the Massachusetts State Plumbing Code a tfjg142 ofjthe ural Laws. _
FBy - �7itle
ity/Town i
APPROVED (OFFICE USE ONLY)
ure of Licensed lumber
Type of License: b aster ❑Journeyman
License Number__ g ��
f /Location
Date
TOWN OF NORTH ANDOVER
1p� Certificate of Occupancy $
�> Building/Frame Permit Fee $
FoundaftlaeV ME $
ott er- it4II�Q1/� COLLECT
I
,2,I- (--1-'
Sewer Connection Fee $
Water ction Fee $
TOTAI„1 ( , 7 409 $
►A er � ,ojQg51 �. rs•
►r ( Building Inspector
Div. Public Works
Locationh
No./-�� Date
�� 3
NaRTM TOWN OF NORTH ANDOVER
Cf
•t�•o •�h
A Certificate of Occupancy $
�-
Building/Frame Permit Fee $
�'� MUS -Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
,,g"ter Connection Fee $
9 TOTAL
J ?�� Building Inspector
{ ' � 6704 Div. Public Works
a l -
Location r�-� /.• �' !� i 1 /_ r / .�
No. Date�-
HpRTq. TOWN OF NORTH ANDOVER
.°3 Certificate of Occupancy $ lIb /0'v� rj?_
Building/Frame Permit Fee $
,S., CMUStt� Foundation Permit Fee $ -'%i Z
v
Other Permit Fee $
OCj O F pS wer Connection Fee $
nnection F �_% iav"7 a
lite2 Fee $ -�
r -Building Inspector
Div. Public Works
410cation
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ --'"----
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
14r:onnection Fee $
TOTAL C. w
Building Inspector
Div. Public Works
Location rk�!
No. y.�` Date
v
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Yr O, r Permit Fee
MY7 -u0 .
e er Connection Fee
;0/4-1 V„VgtQr Connection Fee
TOTAL
C/
$
/lJ OO.O.G
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: - J Ite2(,u °d-0 g 641L /-Z / 2vs. Phone 9 3 7 - 71710'
LOCATION: Assessor's Map Number
Subdivision ��� � `e
Street
Parcel
Lot (s) -0 Ir
St. Number 3(o(
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
�! Date Approved - 1?116 Az
Conservation Administrator Date Rejected
Comments
AA1Y ss DSS 0-BIys7-,?uc7-,1641Chew
-'Public Works - a/water connections /h��/SSq ZkJW
V -
driveway permit
hard wired smoke detector required permit to be pulled
1,,F'ire Department atsfire Dept priortto inst lation
914 -`92 -
Received by Building Inspector
Date
Date
Approved
Tow Plann r
Date
Rejected
Comments
Date
Approved
/l 15 /yam
Health Agent
Date
Rejected
Comments _66,VQ)r-14N/94 QV
V4,L16,0-110 o,- DEEP
/1026-5
-7'.IQve 7-6
AA1Y ss DSS 0-BIys7-,?uc7-,1641Chew
-'Public Works - a/water connections /h��/SSq ZkJW
V -
driveway permit
hard wired smoke detector required permit to be pulled
1,,F'ire Department atsfire Dept priortto inst lation
914 -`92 -
Received by Building Inspector
Date
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PLAN OF LAND
I
NORTH ANDOVER, SASS.
c H O WING
" AS BUILT " FOUNDATION LOCATION
LOT # (H - CANIDLESTICK Po^o
PREP A,RED FOR -
F_ D
ORSEo RAUsF-o
SCALE 1'= 40'
DATE' OCTOBER ZI, 19!52
ZONING DISTRICT
R- I = REsic)c NcE I D ISTPICT
(PREVIOUSLY APP>?OvE o Stj6olV/S1ON
U MDER R-2 ZONE -JUL( I, 1088)
N O T E
PROPERTY LINE DATA TAKEN FROM A PLAN B.Y
THOMAS E. NEVE A5SOCIATES, INC.
DATED NIOV_ 19, 1!)86 FREV(SCO M
JULY (, I D88
HEREBY CEH TIF Y THAT THE FOUNDATION ON THIS
PROPERTY IS LOCATED AS SHOWN ON PLANS AND
COMPLIES WITH THE ZONING REQUIREMENTS OF
THE TOWN OF NORTH ANc)o\/ER, MAS,S..
IN MY OPINION THIS FOUNDATic7N IS NOT IN A FLOOD
HAZARD ZONE AS SHOWN ON THE U. S. D H. U. D.
FLOOD HAZARD BOUNDARY MAPS --
i
ry : QCT 2 2 LIQ
THOMAS E. NEVE ASSOCIATES, INC.
ENGINEERS -SURVEYORS -LAND USE PLANNERS
447 OLD BOSTON ROAD - U. S. ROUTE # 1
TOPSFIELD ,MASS, 508-887-8586
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