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HomeMy WebLinkAboutMiscellaneous - 38 MABLIN AVENUE 4/30/201811719 IV . This certifies that ............................................. C) \, has permission to perform ..................................................................S"..................... .......... plumbing in the buildings of..... 3..X ........... bl ... .. ............ A4.e ....... ...... .... ...... .. . ...... .... ......... .... at ....................... k.0.0..�.RA .................................... North Andover, Mass. ... --j Fee .... Lic. No, PLUMBING INSPECTOR " Check IT TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING P TYPE OR PRINT CLEARLY FIXTURES 7 BATHTUB MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Q,� �, MA DATES PERMIT# 11119 JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS .S ci C _ TEL .> a OCCUPANCY TYPE COMMERCIAL Q ED ATIONAL © RESIDENTIAL NEW: 0 RENOVATION: Ell FLOOR- I BSM CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ REPLACEMENT: Z PLANS SUBMITTED: YES ® NO© MW 40 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d OTHER TYPE OF INDEMNITY El BOND 0 12 1 13 1 14 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 101 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMB S NAME ( LICENSE # SIGNATURE (VIP i JP Q CORPORATION 0#PARTNERSHIP©#LLC[ COMPANY NAME Py ` ng ;ADDRESS Sac sl - _ CITY STATE ZIP �� r ca M TEL FAX CELL �� EMAIL V) 7— orl z N ❑ w a The Commonwealth of Massachusetts = Department oflndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: 05 9e, City/State/Zip: 4 Phone #: iCf �v ��-- Are you an employer? Check the appropriate box: 1. ❑ I am a employer with _employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.❑ I am a homeowner doing all work myself. [No workers' comp. -insurance required.] t 4. ❑ 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. ❑ 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.$ 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. [] New construction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. ❑ ical repairs or additions 12.. Plumbing repairs or additions 13. [] Roof repairs 14. [] Other *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-coriiraciors 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. Insurance Company Name:�e'� Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: V - ( ( ` 7k �, — City/State/Zip: Attach a copy of the workers' compensation policy decl ration 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 under thel&ins and peVlties ofperjury that the information provided above is true and correct. Ik C .� CIL Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # ��� o 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 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 bf 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=contractor(s) 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 cityor 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 (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 permit 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 W:] Date.... TOWN OF NORTH ANDOVER - r� eell PERMIT FOR WIRING This certifies that ...... ..... j ce c............. ..................... has permission to perform `....V.0—ox...... . A*/ wiring in the building of ............ ............................ at.16 ............. t... North Andover, Mass. .......................................................... Fee...-. .............. LiC'. No. Jb.3 9W ....... .... ....... ELEcTRiCAL'INSPE diP Check# 4?iy 7 10731 _;G r I t.oaunonwea& o j�c/M7a zi3ac"ifa .LJeparr`martt o�.}ire �artricee BOARD OF FIRE PREVENTION REGULATIONS Official t:se Only I Permit No. �* r Occupanc) and Fee Checked Rev. 11071 (leave blank) e APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All Luork to be performed in accordance u ith the Ma.sachusetts Electrical Gude iMEQ,, 527 C:M 12.00 (PLEASE_ PRINT LV I;Vk OR TYPE ALL INWORAIATfo., t1 Date: 9 r v�— City or Town of: &JAM �N D©U�2 To the Inspeer r WW'ires By this application the undersigned gives notice ofhis or her intention to perform the electrical wort: described below. Location (Street & Number) 39 /Yl r96L/a/ AUf_ Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit" Yes ❑ No � (Check Appropriate Box) Purpose of Building r� Utility Authorization No. �� C16 591 Existing Service /06 Amps /rid / 010 Volts Overhead Undgrd ❑ No. of Meters 0* New Service W ,Amps /90 1dq0 Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity .Location and Nature of Proposed Electrical Work: � ["�U%�� CI��N� e Completion of the loll"In table mai be waived ha: the Ins ctor o Wires No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires A ve In- Swimming Pool rnd. rnd. ❑ o. o Emergency Lighting 'Battery Units No. of Receptacle Outlets No. of Oil Burners FIREALARMS No. of Zones No. of Switches No. of Gas Burners o. o rection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers eat um Totals umber _..........._.........._._._. ons o. o et - ontam Detection./Alerting Devices No. of Dishwashers Space/Area Heating -KW MunicipalConnection ElOther Local Els No. of Dryers Heating Appliances KW curity stems: No. of vices or uivalent No. o Water KW Heaters a o. o o, o Si s Ballasts Data Wiring: No. of Devices or f4uJivalent No. Hydromassage Bathtubs No. of MotorsTotal HP elecommunicationsiringg No. of Devices or E uivaient OTHER: Artach additional derail ifdestred, or us required by the Inspector n' N,.re�. Estimated Value of Ele trica Work: (When required by municipal policy.) Work to Start: 3 A / 11A Inspections to be requested in accordance with MEC Rule 10. and upon completion. INSURANCE COV RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE FKI BOND ❑ OTHER ❑ (Specify:) I certify. under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Bu den Electric & Security Systems, Inc. LIC. NO.: 16324A Licensee: John J. Bugden Signature LIC. NO.: 2H575E 1f applicable. enter 'exempt" in the license number line./ C7 --Bus. Tel. No.: 781944-�,,O7�000 Address: 87 Franklin Street Reading, MA o1867 -u69 - Alt. Tel. No.:"l- Alan_07406 CeLL- *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. ClPt lgtoo OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee sloes not have the liability insurance coverage normally required by law. By my signature below. I hereby waive this requirement. I am the (check one) [] owner owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: S 55 r1 N • Location k + Noa Date Cy - TOWN % . NORTIy TOWN OF NORTH ANDOVER * ; Certificate Occupancy ; of $ bArwl't� �ss�cMusa Building/Frame /Frame Permit Fee 9 $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $� .� Check # V� 1674 .��� `i Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �u V BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/In ctor of Buildings Date SECTION 1- SITE INFORMATION -%,3.: 1.1 Pr erty Address: 1.2 Assessors Map and Parcrl Number:. , ^' �iI%�/i� _ C t����� • � ` � v \ � � :M� �t Yom. x� Map Number Parcel Number 1.3 Zoning lnfonination: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) Frontage ft �` �' 4 1.6 BUILDING SETBACKS(ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 . Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ownpr of Record Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: SInature Tele on SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Constr tion S rvisor: s� Not Applicable ❑ 7Akd CCS' Licensed Construction upervisor: _ License Number Address �p ✓ , vG *,at,,ed Expiration Date 3.2 .Registered Home Impr ent Contractor Not Applicable ❑ Corctpany Name 31eiRegistration Number ress 'G ��" ^'" Expiration Date Si nature Telephone SECTION 4 - WORKERS COMPENSATION (XG.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 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building 0 Repair(s) 0 Alterations(s) 7ddition 0 Accessory Bldg. ❑ Demolition 0 Other ❑ Specify 3B f Description of Proposed Work: r SECTION 6 - ESTIMATED CONSTRUCTION COSTS Ite / ��D / Estnnated Cost (Dollar) to be d J Completed by permit applicant fFI♦ICIAY USE ONLit 1.T 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 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT.OR.,C, IdT ACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize - to act on My behalf, in all matters relative to work authorized by this building permit applicati/J Signature of Owner Date �a SECTION 7b OWNIF,R/AUTHORIZED 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 Signature of Owner/Agent NO. OF STORIES '; 'D�te !�. " 41 , : ti .:, , r' ,r. SIZES BASEMENT OR SLAB SIZE OF FLOOR TIMBERS I ST 2ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS R . DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION —THICKNESS SIZE OF FOOTING X - MATERIAL OF CIUVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ::ure Location: Cfly The rvOfniJdOT?:SWaahr Of oopc tment of TndwtridAxiknU Of Imwtodtiorra 600 WdsaVWn St"St (Bostom WA 02111 Workers' Compensation ISINUM0e A15clmt D I am a homeowner performing all work myself. F►l r Telephont #: �--- 0 i arr, sole proprietor and have no one working is et_y cgaeity D I am as employer providing workers' compenAfm for my employees working on this job Company Named A .i ' G I am (circle one) sole proprietor, genual contractor or homeowner and have tures •be contratters L*t4 below who hale; the following workers' compensation policies: " Company Name: Address: } �ity: lnaut'ance Company: Telephone M Policy 0: Company Name:_ Address: Ciiy, Telephone p..� insurance Company: Policy #1 Attach additional sbeet if necessary r'ai um to secure coverage as recraired under Section. 25A of MGL 15B can lead to the unposition of criminal penalties of a fine wp to 51,500.00 andior one years' imprisonment as well as civil penaltits in the forth of a STOP WORK ORDER and a fire of 5100.00 a day against. me. I underm-id tbat a copy of this statement may be forwarded to th:e Office of Investigations of the IMA for coverage :,enfication. I do hereby certify under the pains and pen Pies of perjury rhar the information above is true and correct` Signature: Date: �2`TLa Pririi Name;; K al 1G � 0-0 k_1�Q ?none Al lam_ _ Official Use ONLY - Do not write Su this area c Building .apartment Ity or T ,!,ri ParmULicanase M c L'inensing BoarC o Selectmen's Office C Health CGe,)artment 0 Check if immediate response is requirso 0 Other _ C/) m M m DO VJ U) 0 CO) CD az O O ar O Co Cno nto .0 � o O O CL Q CD O .... a: C2 a a Co CD a. CA 'C CD 0 O CO) O CO) n CD O CD CO)CD CD CO) O O CD 0 CD 44 w c?�O m = C �• V� O cr N ap5m 10 CO) »m 0CD co m !� Z m =r'p N a) m N '7'1 I . _ _CL =r m ��d = y m O m N C C m m a _ n ® o'o O O N•0 'm W � O -0 CA ' a �� 0 30 V J^ mcn CD � o m .rt N Z NNdd __. cr CL CO)rCD co n W- Can ' C m �} _ :CA19 O o Z CoA a ='s ..WOE N 3 Qua bd C O m V J .T co) I '� � : O CDp C=2 � r: = m mm: Cl) =s: C O om Lmr c o M c w `D d e o o�c ]' z w ( ; o n o W 0 n -x n o 03 z�� cn c rD CA ro o rD c O M oNq go 0 c C astricone Roofing & Siding REPAIRS FREE ESTIMATES Telephone (978) 682-4266 MARIO CASTRICONE 31 Court Street, North Andover, Mass. 01845 I/we, the owner (s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and conditions, on pre is s below. described: e, Owner's Name... .................................................. ..... �............................ Job Address..tJ ...i � ' ........................................City.. `'-"� ?%`L:. State��`C ... .......................... . . .......... .... ........................... `.:-4x->...... SPECIFICATIONS ................................... :....?."C........................................................... ....................................................................................................................................................................................................... ......................................................................................................................................................................................:........................................................... ........................................................................................................................................................................................................................................................... . ........................................................................................................................................................................................................:................................................ ................................................................................................................................................................................................. .......................... ............................................................4.. ................................................................................................. . Materials and labor to cost $ ......................................... Payable......................................... on ............... and balance in........... monthly installments of $ .........................................each, payable on ........................................day of each and every month thereafter until paid in full (..............% charge per year is to be added to above cost of labor and materials and is included in monthly payments.) Contractor will do all of said work in a good workmanlike manner. Upon completion of above work, all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation and completion as requested by the contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpai immediately due and payable. It is agreed that if permitted by law contractor shall be paid by the owner(s), all reasonable costs, attorney fees and expenses, i addition to the amount due and unpaid, that shall be incurred in enforcing the terms and conditions of this contract and/or any lien in connection therewith. It is further agreed that this contract may be assigned by contractor; and also that the obligations hereof shall bind and apply to their heirs, successors or estate of the parties. The undersigned warrant(s) that he is (they are) the owner(s) of the above mentioned premises and that legal title thereto stands of record in his (their) name(s PROVISO: This contract shall be void and of no effort if credit approved of owner(s) is refused. There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is th contract dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signe by all parties. Cover attic storage cleaning not included. Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing provisions have been read ar the contents thereof understood and that no representation or agreement not herein contained shall be binding upon the parties and that all of the agreements ar understandings of said parties are contained herein. Owner or Owners are not responsible for Property Damage or Liability while job is in operati IN WITNESS WHEREOF, the parties have hereunto signed their names this ............., day of........................, Accepted: ..1� ` Signed., .... ��.....i�...�..�...�.�::........... Owner (OWNER HAS 3 DAYS IN WHICH TO CANCEL CONTRACT) Signed.......... .................................................................. Owner Per. ..... .. :.. �..... . ....................... Signed ................................................................................ Representative % CASTRICONE ROOFING & SIDING CO. 31 Court St, No. Andover, Mass. 01845 A 3 /, 20 11V11A1Vm�, Tei, 682-4266 Location r ca j No. 196,Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ + ; Building/Frame Permit Fee $ ^°''<�' cyuFoundation Permit Fee $ s�st � 2� -Othet-0:ermlt Fee $ + � 'S6wer/Conn�ection Fee $ Watwtonrnection�Fee $ _ &VTOTALel $ Z `J S,6t Building Inspector Div. Public Works PERMIT NO. C'/V APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. V PAGE 1 MAP i'40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SUB DIV. LOT NO. �- OCATION `yam PURPOSE OF BUILDING /1 \, ,.�,,� -`.1` C OWNER'S NAME t' �I ` l� NO. OF STORIES Y-IG�•/� OWNER'S ADDRESS V� �1 BASEMENT OR SLAB ARCHITECT'S NAME - SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �v(�I� SPAN DISTANCE TO NEAREST BUILDING -- DIMENSIONS OF SILLS POSTS DISTANCE FROM STREET DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS SEE BOTH SIDES i PAGE 1 FILL OUT SECTIONS I - 3 PAGE 2 FILL OUT SECTIONS I - 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 3 ®`3 -9 1 SIGNATURE OFQ OWN FEE v e-�av PERMIT GRANTED 19 AGENT OWNER TEL. S tO C0NTR. TEL. # 211 �' rnNTR. LIC. # gt 9 K —'% 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST I� ,� EST. BLDG. COST PER SQ.'Fr. . EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN BUILDING INSPECTOR 'NV'ld 101d S30V1d3Ll SIHl 'a3SOdWIM3df1S '013 'S3EJV21 -VE) 'S3H0210d H11M 'SVNIO11f18 d0 SNOISN3W1a 10VX3 4NV S3N11 101 WOldd 30NV1S1a ONV 101 d0SN01SN3WI0 10VX3 MOHSiSf1W N01103S SIHl Z l I A0N Vd f1000 l - (310331 oNiaiine ONIIV3H ON —I PIE I i +'1 P -L 1.w.9 DIdID313 110 SWOOV dO 'ON L SVO SM31V3H 11N(1 0.1.H 1NVIOVM `.)NINOIIIONOJ MIV MOdVA MO a,1.M IOH _ SM31dVM OOOM 'S10:) T 'SW9 1331S WV31S _ 510 18 'SW9 M39W11 'NMni 41V IOH 03JMOd 3JVNMn3 SS3l3dId 1SIOf OOOM ONIIV3H ll I ONIWVIIi 9 00V0 3111 dOOIA 3111 _ S3Mn1X13 NS30OW ONHOOM 11011 d3MOHS llV1S 13AV80 '8 MVI _ ON19Wnld ON 31V1S ANIS N3H11X S30NIHS (lOOM AMOIVAVI S319NIHS 11VHdSV 13SO15 M31VM 03HS IVI4 13M9WVE) 'X13 L) wM 131101 OMVSNVW 'Xld E H1V9 dIH I I 319VO Mawnld OL JOOHLNON 5 �I 32101b M Od dns ONISIM —I M0013 8 'SM1S DIIIV 3WV43 NO 3NO1S AMNOSVW NO 3NO1S A19 M30NID MO 'JNO:) 3WV43 NO ADIM9 AMNOSVW NO ADIM9 —� _E-- E t 9 3111 'HdSV NOVJWOD 3WV83 NO 0O�11S AMNOSVW NO OJ" IS ONIOIS '1M3A ONIOIS SO1S39S7V O.hk0dVH ONIOIS 1fVHdSV H16V3 S310NIHS DOOM 313MDN0D MVIOM0 SO09d SMOOIi 6 II S11VM b N3HJIIA NM300W S3DVld 3M13 V38V DI11V 'N13 V34V .1.W.9 N13 WOOM OV3H 1, W.9 ON % 1/1 '/. lln3 VRV IN3W3SV9 E — — E L — t — _ £ N13Nn 1lVPA AMO — M313V1d SM3Id O.MOMVH 3NO1S MO ADIS9 3NId A.19 313MDNOD 3138:)NOD HSINIA 80I83INI 9 NOIIVONnoi Z N011011211S N00 SIWW1MVdV _— S3DIJJO—_ AIIWVA '111nW S3IMOIS AIIWVJ 316NIS Z l I A0N Vd f1000 l - (310331 oNiaiine Cl)MA <D o m w 'n m 7 nQ (A tit (j) m O T m 7 r< 3 O n: m � 7 C c W O r T 0 Z m O O z TT 0 v O ° O T _ S Poo O � b m e m _20 (% �f a.�nX� ... ... C Z A "• O "O o pop PO 3 y H O A we POO '� O .^ rt a00 1`I► 80 O H r: Vl Z a vcr 0 Cl)MA <D o m w 'n m 7 nQ (A tit (j) m mT 7 T m 7 r< 3 T n: m � 7 C c W O T T T 0 Z m O z TT 0 C z 00 ° O T _