HomeMy WebLinkAboutMiscellaneous - 372 MAIN STREET 4/30/2018IN
Location % _ %¢ /h19iiv
No. hoz Date
/ A
TOWN OF NORTH ANDOVE8
0
Certificate of Occupancy $ K;
dv
Building/Frame Permit Fee $ 3g '
Foundation Permit Fee $
WD
Other Permit Fee $
Sewer Connection Fee $ T
Water Connection Fee $ o
TOTAL
I /fir eta ��-r LL
d -x-` mac, / 7
1° 9445
f
Building I'rTrpector
Div. Public Works
IA
> m
0
m m
0
x
F m
r
0 °
c m
i q
U)
m
n
i
0
z
to
w
w
A
0
m
Z
0
3
0
Z
C
=
O
0
A
n
z Z
m
o
g
>
m m
r
N
D
r
m
m
m
m
.q(
-1
ql
r
n
2
z
D
A
r
C[
LIZ,
IA
> m
0
m m
0
x
F m
r
0 °
c m
i q
U)
m
n
i
0
z
to
w
w
A
0
m
Z
0
3
0
Z
C
m
y>
o
o
g
>
o
r
N
D
r
m
m
m
m
.q(
-1
ql
r
n
2
z
D
A
r
C[
C
>
>
D
D
v
x
m
m
m
c
n
n
n
A
m
0
y
0
0
0
0
m
m
m
N
0
0
r-
>
r
o
rm
T
i
0
Z
to
>
o>
z
Z
Z
r
m
A
3
A
3
>
v
x
m
>
0
o
o
f
m
3>
m
m
m
N
n
O
A
i
0
-Ni
A
m
W
>
z>
+�
O
i
m
om
1
A
_i
0
Z
z
m
i
i
N
r
0
3
Z
m
q
pp-
i�'
?
W
>
rn A
n
U)
v
2
0
"\l
v
Z
0
Z
<
[
m
�1
m
q
<
3
0
�
W
0.
0
(�
0
A
0
,
m
i
m
b
>
0
A
m
m
m
m
m
Nm
°
9
N
>
0
C
N
c
c
c
m
m
m
2
'"
m
0
9
c
A
0=
Z
0
3
m
0
O
O
O
O>
-q
i
6
z
m
m
m
r
0,
Z
r
i
i
n
0
0
0
0
0
0
0
m
m
0
OA
A
0
0 0
n
z
C
Z
A
m
o
Z
Z
2
q
x
(7
C
a
0
q
-�
>
0
2
2
2
0
3
>
A
O
n
n
n
r
Z
-4°
'"
1
q
r
m
m
0
m
m
m°<
o
Z
a
q
Z
v
O
v
A
0
0
0
m
rI
i�
N
4*
I
f
o
I
z
A
z
z
r
'v
>
m
f>
v
fdi
N
m
m
A
m
A
m
D
r
x
Z
°
z
x
m
m
z
N�
0
X
0
9
D
ml
0
ae
O
W
W
m
00
0
IL cA
w
UI
Z
Nd
°I
Z�z
0Waa..
j0F.
LL
0°a
ZEN
OMW
NWg
moa
low
Z
°0N
UNI
QZF-
w�W
it 0
u
�xE
?WW
�Z�
ZQN
ONW
u
WwZ
N 1IOQ
u
Z
Q
IL
D
u
u
0
clI
�-TFFFI I I-
W
_
II ITI
8 0
0
Z
—I TILT
i`
_I
G
Z
N
p
O
O
_2
K
d Z
T
m
_
x
W
Z`"
>
_2
I I I
O
bl
��
aQ
W
.p
3
I
')
(VW
YC��=
W
Q
ZQ
Mo.
Z
W
Z
0
W
=
V
W
V Y
W
a
X
W f
zz 3x�
} u m p
W 0 0
x
��—
W O
0�=�
o
z
ww
Q
wa
�~�Z
mQ
dQ
J
v
�Q
O
�°CV�
WfNZO<
p J
W Q
,nx
�Z�-w
O
UQ
y V
0
u
2
Ny
Q}
Z
V?
Z�
2
�d
U
-
wp
d W
O
2
a x d J
> V
p
J J
-�U
wne
Q 3
a�-
p N
V x
�A 0
00
d
2 d
Q
�y �y
zy
O
w x
pV Q
Q
N Q^
m
3 Y Z N
1- t-
d O
Vl x
Q oac c9
O W Z
F.
U
Q
~
ZQ
W
W
wU
Z
aQ0ZoOC
0Z
W
Or
d Q
NWJ
OWZ
3
m
0
OZ
Q Q
�
Z
ZOWZ
W
VOm
NWLLoQc
_Hc
O
N
ma
O
ft
Q
Z
z
O
Z0
ZZ
>
�x
pm
6
4Z
O
nOjmNQ
0000
00
Zai
tea..
a Pat,
`0 4n
� � • �•. ,� as � a 3 T
y
ati tiomo j 3 O
CD` O O o t' ti �+ T
• Z n Z2my
cb C
C:'
g
� Ro
�• y Q7
coi
m m cco
Clip ��4m IZti
CD O L o
tiIz
p O
lzt Cb
c y
07 O CD
y y
CD
r o
�o CD
•� C*
CS o :V
O D
CO) Czy
i� Cob
O Al
CD
Cj y m ?� F -1
+v O
O !�
w -
83
o a:
o ti'
hG Z CID
o a: rD
tzRE
a O
y p z z ^• c � '�
a
�O
K
• w i
F4�N� b'� .J:..Z n .• -- ��_ .:: .2; > .� t Y � V'1 -R h k � l`�enrm _"
r OFFICES OF.
APPEALS �- Of �` - _ 120 nnain scree:.'
�.�►:-JNORTH ANDOVER `North i�ridover,
BUILDING Massachusetts O t 845
CONSERVATION DIVISION OF
HEALTH
PI ANN ING PLANNING & COMMUNITY DEVELOPMENT
KARE:` H.P. NELSON, DIRECTOR a- "
x - -
In accordance wt c-isic �S cf f-7 c S ,
the S -t, a condition of Building Permit
Number
is that the dctrls resulting from this work shall be
disnosed of in a prcpe: Y ;iG.aw ;slid waste dis^csai :acilir: :c::aec; y 1
b , 1GL c III, S
The debris will be disposesLi of in:
k—c=ticn cf F acilit,•)
Signature of Permit Applicant
b �!P�
Date
:TOTE: Demolition permit from the Town of :forth Andover must be obtained for
this project through the Office of the Building Inspector.
Date. ..�...� .:C'.�......
TOWN OF NORTH ANDOVER
" 9
-�J I PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation ...................
in the buildings of . .� . r'
at .)7.`.1.h7%....... ....... . . . . ... North Andover, Mass.
Fee. )-. 1 .... Lic. No..,/.,. .. . z \....... .
/GAS INSPECTOR
Check #
369
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
_ (Print or Type)
-__ a
/VOQr# /�w'0a VN p Mass. Date NO d` J
.r1;9 Permit #
ft
Building
er's Name ty R z. p a L G t!
Type of Occupancy
New ❑ Renovation ❑ Replace\/ent Plans Submitted: Yes❑ No ❑
Installing Company Name G�rMA/u 1` r Check one: Certificate
Address 2 M!}�Zl�.rl� le��� ❑ Corporation
19 ML ) D VFX cPartnership P
Business Telephone V75- 3 t`a ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter has �14
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142,
Yes 4 No LJ
If you have checked Yes. please indicate the type coverage by checking the appropriate box.
A liability insurance policy ZI Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my'
knowledge and that all plumbing work and installations performed under the permit issued for this application will be.in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. n/ -
BY T of License:
Plumber Sign re of Licensed Plumber or Gas Fitter
Title . Gasfitter 6 3 F' S
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE. ONLY)
N
Q
N
W
N
N
N
Y
U
=
tL
2
F-
N
In
V7
0
0
O0
o
u
Q
c
o
m
us
Q
m
us
u
m
W
H
rn
a.
O
c
o
4
4
N
N
W
2
V
W
T
Q
N
Z
W
Q
=
C>
F-
O
F�
S
W
W
Q*
J
Q
2
W
Q
W
a
¢
O
W
>
U.
W
y
Ct
W
Z
Q
Q
W
W¢
>
w
C
2.
Q
Q
a
O
O
W
O
as
+ Su6—es5ildi.
+
+
1
1
BASEMENT
1ST.FLOOR
!
2ND FLOOR
``
1
3RD FLOOR
4TH FLO.OR
i
5TH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name G�rMA/u 1` r Check one: Certificate
Address 2 M!}�Zl�.rl� le��� ❑ Corporation
19 ML ) D VFX cPartnership P
Business Telephone V75- 3 t`a ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter has �14
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142,
Yes 4 No LJ
If you have checked Yes. please indicate the type coverage by checking the appropriate box.
A liability insurance policy ZI Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Owner❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my'
knowledge and that all plumbing work and installations performed under the permit issued for this application will be.in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. n/ -
BY T of License:
Plumber Sign re of Licensed Plumber or Gas Fitter
Title . Gasfitter 6 3 F' S
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE. ONLY)
3 Qa i3) J %Yl 4u s�-
Location � � 1
L/
No. �7 8 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
•, sACNUSEt� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ q D
Check # /'0 -0
1 639 ,� r
Building Inspector
The Commonwealth of Massachusetts
1.2 Assessors Map and Parcel Number.
State Board of Building Regulations and
TOWN OF NORTH ANDOVER
Standards
BUILDING DEPARTMENT
Massachusetts State Building code
1.4 Property Dimensions:
780 CMR
Zonis Distrix Use
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY
BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING
Building Permit Number: Ll
9 /V
I Date Issued: / _ / q —D-3
CF1'TIAN 1. CITF. iNRAQM A'r'rAN
1.1 Property Address 72 — 374
�F' Inh,u �;
1.2 Assessors Map and Parcel Number.
/(
_ 16 V
Name (Print)
Map Number
Pared Number
1.3 Zoning Information:
1.4 Property Dimensions:
7f- //
Zonis Distrix Use
Lot Area (sq)
Frontage(ft)
IFront Yard I Side Yard I Rear Yard
Required I Provided IRequired IProvides IRequired Provided
107 Water Supply 4M.G.L.C.40.4 54 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public O 13 Zone Q Outside Flood Zone Private O Municipal a On Site Disposal System 13
2.1 Ownerof Record
—nteFY
12 & -X LTY /e V S7 f—
Qp
_
Name (Print)
Address:
Si lure
t Telephone
7f- //
2.2 Authorized Agent:
�/�k l /J
U'�—
Name (Print
— Adidress
c
Ai 6ESi �•
Signature
Telephone
(
9 78 - 6fG 5 --7//7
SECTION 3 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE
3.1 Licensed Construction Supervisor:
Not Applicable Q
Licensed Construction Supervisor:
License Number
Address
Expiration Date
Signature
Telephone
3.2 Registen� Home Improvement Contractor.
Not Applicable Q
Company Name ,
)64
Registration Number
Address
,
Expiration Date
Signature
Telephone VYOSQt
Kevisea iv9 i imu /
M3
/j
SECTION 6 - DESCRIPTION OF PROPOSED WORK check all applicable)
New Construction 0 1 Existing Building Repairs (3 Alterations Addition 0
Accessory Bldg. I Demolition W I Other 0 Specify
Brief Description of Proposed SCE AZT
SECTION 7 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP Check as applicable)
A Assembly A-1 A-2 A-3
A-4 A-5
B Business 0
E Educational 0
F Factory 0
F-1 F-2
H High Hazard 0
1B
1 Institutional 0
1-1 1-2 1-3
M Mercantile 0
2B
R Residential 0
R-1 R-2 R-3
S Storage 0
S-1 S-2
U Utility 0
Specify:
M Mixed Use Q
Specify:
S Special 0
Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,
ADDITIONS AND/OR CHANGE IN USE
Existing Use Group:
Proposed Use Group:
Existing Hazard Index (780 CMR 34)
SECTION 8 - Building Height and Area
BUILDING AREA
Number of Floors or stories include
basement levels .
Floor Area per Floor (so
Total Area (sf)
Total Height (ft)
CONSTRUCTION TYPE
lA
0
1B
0
2A
0
2B
0
2C
0
3A
0
3B
0
4
0
5A
Q
513
0
Proposed Hazard Index (780 CMR 34)
Existing (if applicable)
SECTION 9 - STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required
SECTION Ta - OWNER
OWNERSAGENT OR C,
1, _
hereby
my bel
TION - TO BE COMPLETED WHEN
APPLIES FOR BUILDING PERMIT
ive to work authorized by this building permit application.
Date
revised bldg form/state JMC
Yes 0
Proposed
No 0
As Owner of subject property
to act on
SECTION 10b - OWNER/AUTHORIZED AGENT DECLARATION
I,� " , as Owner/Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
C C c
Print Name „
Signature of Owner/Agent Date
Item Estimated Cost (Dollars) to
be completed b permit
applicant
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 +2+3+4+5
Official Use Only
(a) Building Permit Fee
Multiplier
(b) Estimated Total Cost of /
Construction from (6)
Building Permit Fee (a)x(b)
r
Check Number /
Proposed Work
• Demolish and rebuild roof over (2) porches, membrane roofing to
be used on both roofs
• Demolish (1) existing deck over roof
• Build (2) 23' x 6' decks above porches. Frame to be constructed
using Pressure Treated lumber,
Decking material: Choice° decking; Custom-made balusters to
match existing style
• Remove (2) double -hung windows
• Frame opening and Install (2) Andersen Frenchwood° Gliding
Patio Doors
• Demolish (1) existing partition on second floor
• Remove approx. 125 sq.ft. ceiling tiles; replace with blue board to
meet adjacent ceiling; apply a skim coat of plaster over entire
ceiling approx. 22' x 12'
• Remove wall to wall carpeting
• Create passageway to an adjoining room through an existing
closet
• Electrical requirements: move (2) outlets; provide CATV run from
entry point to 2nd floor living room
• Install Crown Molding (primed) around perimeter of room approx.
22'x 12'
Town of North Andover
Building Department
27 Charles Street
North Andover MA 01845
Tel: 978-688-9545
HOMEOWNER LICENSE EXEMPTION
Please print.
DATE 4,117/D •�
JOB LOCATION J7Z' .i17 yUII7� 51 W
Number Street Address Section of Town
Q
"HOMEOWNER ;Y-6fS--7//% 9,7661i(/o -2766
Number Home Phone Work Phone
PRESENT MAILING ADDRESS / %f// / D? Ct— 'S,E�
0 4114-
City Town State Zip Code
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 "homeowner" certifies
Building Department minimum inspectio
comply with said procedures qnd requir(,
HOMEOWNER'S SIGNATUR
APPROVAL OF BUILDING OFFICIAL
he understands the Town of No. Andover
ures ane�F'equirements and that he/she will
Note: Three family dwelling 35,000 cubic feet, or larger, will be required to comply with
State Building Code Section 127.0 Construction Control.
7
ski
NA
5
ORR» .., £•,. w+
am. �
4 Y 1
,N f
n
! r
L
Ja G
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 a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
4J4s TF MAIX 6- EME/i
(Location of Facility)
Sig ature of Permit Applicant
7A -3
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
17'
110' TO
DAVIS STREET
CERTIFIED PLOT PLAN
LOCATED IN NORTH ANDOVER, MASS.
SCALE) "=20' DA TE.
ScoftL. Giles R.P.L.S.
Frank. S. Giles R. P. L. S.
50 Deer Meadow Road
North Andover, Mass. 37.35'
35.6' �P�
ASSESSORS MAP 43
PARCEL 90
r� 9375+/- S.F.
EXISTING HSE.
FND.
#372 #374
MAIN STREET
OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY
AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY
WHEN CONSTRUCTED.
o
N
Q.
Q.
z
2
�
w
w
24'
EXISTING HSE.
FND.
#372 #374
MAIN STREET
OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY
AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY
WHEN CONSTRUCTED.
C/)
J)
C
J)
Cl)
0
m
CA
CDZ
CD
c. r
� d
CD
d
.o 0
0 0
CL
C7
CD o
F-wom ..
Min
Q o
Cfl CD
CO)
10
CD
0
C2
y
d
d
0
y
cm)•
O
CA
d
C)
0
CD
CD
y
CD
CA
0
CD
0
CD
= -4
y O Q y =
FL, oSo �n
CIm L o c7
Z H O d c 3• =
=r -O y
so co 0., ._. = --► O y T
�a"'a m
=r CO)
N
i
O C=3) �m a
O
to
O
O y O
oo O s
3 m
/ n O y OtTl 5O
V J [�
c = m
nm
}• O y Z d d Q
ccnn Vr.�a
CL
CIO O
�--+� ----++ y
�. n 2 m C=-9
CD
o� o
CD C
y
O C O
s
cn
co
�. Cn
CD C
r. w Z
d dw
(
0
C*
7
rD
0
z
W
cm
�,
x
r
�
z
x
p
m
n
A
ar
�
a
0
C3�
r
�'
O
^
0
A
p.
7C
O
o
1
a
z
0
b
O
C
CD
Date ... ..... .... .... 3
TOWN OF NORTH ANDOVER
'0
PERMIT FOR WIRING
This certifies that ...... pl. IN .....
........./Y C-
................
-
has permission to perform ........ ..........................................
wiri!hg in the building of ... r
i:�.174 .... TY5.t .............
-.7.x..-.33...71 q, It-,
at., .............
.-
�5 .North Ando
�er, ds
Fee.. ........ Lic. NN -.0 - *''*** .... .....
....
0ELECTRICAL
Check # ----
4497 _
�
ThECOA MON4VEUTHOFMASSACHUSEHS Office Use pniy
DEPAR7AffMOFPUBIICSAFM Permit No.
BOARD OFFIREPRLVEAMONREGUTATIONS527CM 12M
Occupancy & Fees Checked
APPLICATIONFOR 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 Jam' /I/03
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)
Owner orqenmt km _v 2 2Y5%~
Owner's Address Wcac- s 1 S7—
Is this permit in conjunction with a building permit: Yes � No (Check Appropriate Box)
Purpose of Building - nz Utility Authorization No. _
Existing Service Amps volts Overhead M Underground No. of Meters
New Service Amps / Volts Overhead l:3 Underground No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed ElectricalWork
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers
Total
KVA
No. of Lighting Fixtures
Swimming Pool
Above
Below
Generators
KVA
.�
round
and
No. of R lteptacle Outlets
No. of Oil Burners
No. of Emergency Lighting Battery Units
,J
7
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS
No. of Zones
No. of Ranges
No. of Air Cond. Total
Tons
Tfs
No_ of Detection and
No. of Disposals
No_ of Heat Total Total
Pumps
Tons
KW
Initiating Devices
No. of Sounding Devices
No. of Dishwashers
Space Area Heating KW
No. of Self Contained
DetectiordSounding Devices
Local Municipal
Other
No. of Dryers
Heating Devices KW
Connections
o
No. of Water Heaters KW
No. of No. of
!
Signs
Bailasis
No. hydro Massage Tubs
No. of Motors
Total. HP
v �
OTHER -
YES NO
IbawstlmiWdva5dptudofsa=uheOffic - YES FyouhavedrclodYFSple=nbcaethetypeofooVrageby
dtaddtgThe box
INSURANCR� 1�1
BOND DHFR (Dewe Specdy) 3
F*ationD&
Esttma�ilvalueof)1Wotk $
w«kmsalt I�s� I=mo w L L C
SOvdundff iePenaltiesofpetjury:
FIRMNAME % I.ioenseNo. _ / ,i -�f9'-,-
Signahue I�oa No �� �3 9
BtlSinmTel No. `97�= 6,<,--.5
A ,:`% ��t � s ST Al Tel No. C'7-7 Jic
OWNER'S INSURANCE WAIVER; Iamawatettvilbel=isedoesnothavetheinsuranoemvenWorits st*sLgr>ialeWvalertas regtmedbyMassachusefts Coral Laws
andlhatmysignahmon ispemritapphcabmwaiwsthisiegtmmot O
(Please check one) Owner F-1AgentQ
Telephone No. PERMIT FEE
Igna ure ot Owner or Agent
Name
Location:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Attidavit
Please Print
City Phone #
I am a homeowner performing 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
Insurance. Co. Policy #
Company name:
Address
City: Phone #
Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the Wnpos%m of criminal penalties of.a fine up to $1,500.00
and/or one years' impmonmentas_nteiLas_c:n! 4wmakms-nlheimn-fA-STDP V4DW-ORDER,and afire-f_(,51110M)arlay.ag,ainstme I
understand that a copy of this statement may be forwarded to the office of Investigations of the DIA for overage verification.
I do hereby certify under the pains and penalties of petlury that the irrfoa whoa provided above ,is true and correct
Signature Date
Print name Pb"4
Official use only do not write in this area to be completed by city or town dWar
City or Town Permit/Licensing
O Building Dept
ElCheck if immediate response is required .p Licensing Board
E] Selectman's Office
Contact person: Phone #. Ei Health Department
Other
Date .. .2.e G 3.
.fie
NparM TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ../, f%`.. . .............. .
has permission to perform ..... P.C.�. �.u!'9.�..
plumbing in the buildings of .14 l t
at ...% 7.............. , North Andover, Mass.
Fee.4�.7....Lic. No../.2. . ...... 't......
PLUMBING INSPECTOR
Check # �� `�
MASSACHUSETTS UNIFORM APPLICATION FOR P" ERMIT TO DO PLUMBING
I
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location Owners Name Permit #
Amount
Type of Occupancy
{
New■RenovationReplacement No
FIXTURES
I I
(Print,ortype) Check one:
� eI ..! .M o aii .il •
CertificateInstalling CompanyName El corp-
� � 1
Partner.
Name of Licensed Plumber:/4/I7 C �-
Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box:
Liability insurance policy IV Other type of indemnity D Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach State Plumb and Chapter 142 of the General -Laws.
(OFFICE USE ONLY
Type of Plumbing License
License MOM- Master
Journeyman 0-