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HomeMy WebLinkAboutMiscellaneous - 380 FOREST STREET 4/30/2018 (2)G 6086 -2 - aj - Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING e. This certifies that ... -;.has permission to perform wiring in the building of ............... ................................................. at ................................. -I& ... lio -9 10� ......... ....................... . North Andover, Mass. 0'........ )� ......... ..... .. Fee.`..-Lic. NdCA14V( .... ELECTRICAL INSPEOrOR Check # W Permit No.®�6 Occupmy &Fees Checked A.PPLICATTONFOR PERMIT70 PERFORM `CIRICAL WORK ALL WORK TO BE PEAPORMED IN ACCORDANCE WITH THE MASSACMSM ELECTRO CODE, 527 CMR 12:00 (PLEASE PRINT IN 'INK OR TYPE ALL VMRMATION) p Town of North Andover To the(nspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street d Owner or Tenant Owner's Address ('A- ✓'7 "`- Is this permit in conjunction with a building permit: Yes ® No [3 (Check Appropriate Boa) Purpose of Building es Utility Authorization No. Existing Service Amps�.V olts Overhead . [3 Underground No. of Meters New Service Amps Volts Overhead C3 Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorkP,+IR 167 C40 Na of Ugh ft Oudde Na of Hot Tubs No. of Tnusibsrmi Told KVA Na Of Uahtins Fixtures Swi miq Pool' Above Below �� KVA No. of Receptacle Outlets No. of OU Bunten No. of Emergency Lighting Battery Uniti Na of Switch Outlet No. of am BOMM FIRE ALARMS No. of ZMN No. of Rw%n No. of Air Cad. Tad Tam Na of Dgxtiao and Na of Disposds Na of Haat TOW Total Pump Kw Initial" Da,ien Na of SMWIN Devices ��• No. of Dishwashea Space Ara Heating KW Na of se f CoathredDete l ocd Do id �� OtharComlections No. of Dryers Heating DrAoes Kw No. of Water Herren Kw Na or No. of Siam Bsiinb No. Hydro Massage Tubs Na of Moron Told HP huwwQNmw Rwumtblhete =nmucfMm@ft lQ mwim Ihmesu6rttril>edvaidproaldsunebfteOttka WbikIDSW SgWundrl RRMNAME "M © I .amt 11>apactionDsteRmtcsiad ar�su6s4rtile�iraist YM NO ayauhgteYKphwirt*atee -Wcf PtpmtaD� o Estrria�dVAZdII�c WWak $ ^-D Pao Brei LiMaeNd, lj�-(,v0 Ia b✓ Stan . Z'Al OWMVSM3ANMWAMI= waelhattheboenee �� d�,��gdleila�ceoovecgeari�a�bsmlrielogtivsls1Nff WdbyMW d�a�C��g ardtt�etmysigtr�eondi'sptwnitappiaitimfiaeequimlot (Please check one) Owner CM Agent Tel hone No. ci eP' FEB 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING Jl (Print or Type) —NORTH ANDOVER Mass. Date . 6/2 19 9 8 Permit #3281 Building Location 380 Forest Street Owner's Name Jung. Type of Occupancy Residential New ❑ Renovation ❑ Replacement IN Plans Submitted: Yes ❑ No ❑ FIXTURES Installing Company Name Heritage Htg, &P1g. Co. Inc. I Check one: Certificate Address35 Pleasant Street CX Corporation 714 Stoneham, Ma 02180 [] Partnership Business Telephone 617-438-7776 8-7776 F-1 Firm/Co. Name of Licensed Plumber Gordon Switzer 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 yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 3 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: Cinnafuro n( flw..n.... n.,...,.•.. e......• 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 the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 f the General Laws. By Signature of Liceni—edPlumber Title City/Town Type of License: Master [X Journeyman ❑ APPROVED (OFFICE USE ONLY License Number -8 3 2 2 N F N J N Z O Y Z C • • W (-•I r -i W Y O W F W rz x N Z O _ Z Z O. _ 1114 -j U (n m (n 3: 2 > Q W H N Y Z_ a W �' C X rif rti •i -r Z n a W Q N z Lr H W U 4 M x W 3 X fA d n Z = J Y N d ¢ rt ~ J Z z p W a W X W a F Q Q S N N Q a O C OJ O OJ Q ¢ x 4 x 4 0 Q I7^R 1+ ��I 0 J 3 x N W LL O 7 0 a l_ N O ^S {i( (f, SUB—BSMT. BASEMENT 1 1ST FLOOR I W 2NDFLOOR A 3RD FLOOR D IT 4TH FLOOR I 5TH FLOOR RI I I S 6TH FLOOR El I 7TH FLOOR C 9 STH FLOOR T D Installing Company Name Heritage Htg, &P1g. Co. Inc. I Check one: Certificate Address35 Pleasant Street CX Corporation 714 Stoneham, Ma 02180 [] Partnership Business Telephone 617-438-7776 8-7776 F-1 Firm/Co. Name of Licensed Plumber Gordon Switzer 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 yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 3 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: Cinnafuro n( flw..n.... n.,...,.•.. e......• 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 the permit issued for this application will be in compliance with all . pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 f the General Laws. By Signature of Liceni—edPlumber Title City/Town Type of License: Master [X Journeyman ❑ APPROVED (OFFICE USE ONLY License Number -8 3 2 2 t J z O w N D w U_ LL LL O ¢ O LL 3 O J w in W W LL O z m J a O a O r r 0 z � z O W J Z a o ¢ m J_ O LL LL O Z O O a < J w 4 Q z J a N2 3721 NORTq Of t, Sao y11Q - � . p Date (�1. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..eJa.�..�. .... t? .°.. r........ . has permission to perform ... 6F,l-).......................... plumbing in the buildings of .. J . v.Itt: ....... ............. . at... ' 4�.�7 ..... orth Andover, Mass. FeeP .'�l,. Lic. No.F ..... .... . PLUMBIN�INSCTC'R 05/08/98 14:12 24.00 RAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer )2 1 592 M Date ..... TOWN OF NORTH ANDOVER A PERMIT FOR WIRING FE g This certifies that ......6-. t r.v.�.....lL�,... .. . `� 3f .......:.......................... has permission to perform ........c..c%�.�........ ....�(�2....................g wiring in the building of ....... r:1.t.z.!.0 ............................................. .f at ..-7.6!.rr........ �,...O fs..l ............S..1 ... ......... ...... . North , Fee. �... Lic. No...o�.fr����.. 1'i73a G� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ThE091tW0NWFALTHOFAf4S"CffL7'SF7TS' Office Use only DEPARTAEWOFPUBUC.S4FETY Permit No. BOARD OF FIRE PREVE1 V170NREGUTAT101 527 1200 � Occupancy &Fees Checked APPLICATION FOR PERA 'T TO ERF® �,E(CMCAL WORK ALL WORK TO BE PERFORMED rN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 6�' / G (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)�O �(� g5—T -s Owner or Tenant ff'12141v IL 4- IM iTG iU (.1 L .{T 2 t c 1 Owner's Address Is this permit in conjunction with a building permit: Purpose of Building Existing Service/00 Amps 1/0 / 2*.)Volts New Service ZC%J Amps/10 W—JVolts Yes m No (Check Appropriate Box) Overhead Overhead Utility Authorization No.. C, Underground r7 No. of Meters 1 Underground ID No. of Meters Number of Feeders and Ampacity • Location and Nature of Proposed Electrical Work I ZZ No. of Lighting Outlets No. of Hot Tubs No. ofTtansformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA and ground No. of Receptacle Outlets •`' No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Bumers FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons 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 Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER • c:r w • '•i. i r w • ;•. •.:.�.• • • ;� • n ;jai :.: i 9. VAN • . WodciDSwt •4�',j!_�_� irnpeaiortDateRecg ted ta>da�iePellaltiesof ' Estar *d VahxdE1ecical Wcd($ Rough Final MNAME ��Cm. 1) . 14 21�S..R... Lim S�S�v►�.e., Liar�eNa Z `1 V — LiMnseNo Bt�Td.Na %1 Z 3 �� �4uLlc A AIL Td.Na OWNER'SMJRANCEWAVER;IammmthattheIioenseLloomit Laws andthatmysig�(xitiispearla Wplicodmwa*rAEdfsm*Mullai (Please check one) Owner Agent ® /�� J ) Telephone No. PERMIT FEE =—� l/y�� - Location`s l% No. Date TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ 4 Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # .'As—& -7 :: 18581 i Building Inspector _ TO" OF NORTH ANDOVER 'BUILDING DEPARTMENT APPLICATION TO CONSTRUCTREP RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED:.�---- �i v � SIGNATURE: Building Commissioner/I r of Buildings Date S SECTION 1- SITE INFORMATION 1.1 Property Address: L 1.2 Assessors Map and Parcel Number: /OG. h— c01,6 Map Number Parcel Number G� 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area Frontage ft 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: I 1.8 Sewerage Disposal System: Public ❑ Private . ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes _ No _ 2.1 Owner ofRecord P-� R i' f✓ 1i 1��� �/ `� 3 F o %° 2 CSS" S 1C Name (Print) Address for Service (-/ (70 y Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signatqrc Telephone SECT ON 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ r+ Licensed Construction Supervisor. Licefk'Nu&ib6r Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expitatim Date Signatit Telephone z M go 0 ro M rmr SEEMZ G) j: SECTION 4 - WORKERS COMPENSATION (KG.L. C 152 § 25c(6) ' Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result 1 in the denial of the issuance of the buildine permit. Signed affidavit Attached Yes ...': O No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ['J/ Alterations(s) ❑ Addition ❑ • r t � Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost (Dollar)'to be Oi?F1�CIAX. USE`UNL1' E� Completed b applican-Wifgt " permit 1. Building (a) Building Permit Fee Multi Tier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) ems! 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 d D Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZE!DAJGENT DECLARATION I, C�e� T N 0 as Owner/Authorized Agent of subject pro�yy Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge q and belief / NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH EY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r CO) m m 4 m m CO) CO) m C2 y CA CD � d 'v O MZ y so O CL CO) n� coCL O Q d CD CSD O C CD tH �■ CD C2 Cc y CO C SO .v y O 'CD CD Z O CD O CD , r I C O C ?= SOCo co � m y Sao m n m es H m dC �, = =- H _4 H T CL m a=r0 O m -'IOmy O y O?m. m 2 �� 0 C �. C .► d Z� n O clim =r H o,m CL • o ? CD m y a3 CD H d y . C I S+ Xm. H p1 1 • nor, fA oma. mo N M CID C3 O O m �C d 0 CD dm: o - c. -C_ n0 y O : n1 = • O �• O W m 9 ?r cn 4 A b7 G� "t7 ='_ jCf ro '„rl w C� Sy° "jJ O ?1 p' �' 'Jd O ; ro `17 9 O � O ^ p a. � � 7d z vi )Mq 0 0 c 'd AMERICAN HOME GUILDERS, INC y���.04 46 Austin St. et elp0ls Nowtonville, MA 02460 (617)332-2400 1-60o-323.0033 IMI. she owner{a) o/ tf+e pramhs% me below. hereby tonlroof wim and swhaiae Amorlean Nome Seeders. kfa, eRa rdelred to as the 'COntraa0r') to furnish all (160621111V(160621111Vm8liftials, lcbor end >.e fOMow �Nrlbed wqh relenrrcso whidl placetilwe Improvements according to the hollowing speclficatiOM. terms and CprbigoM an pr , tt ,. -,S!/c r warrant that It" w record the holder(%) Of 010: {+`1- 6/, •- '4.7 r ^ •vc'f•-�7l Owna'eName^_ M [.e1rL�.-:'•c slaw",/J Job Address C! 111 ✓,(ix icy / vac '�ar .. ks'c ✓ /(.�✓d /- L `= '• c t �.... (� - �" x i • c (� 1[I U C`3 �, ren /i /. 31 A •%'• x ,e•"cCiVrl,D.ri c� Inv r of'p� tabor and materials furnbh$d,by the COnlrNler; the Owner(s) agrees) to Pay the�y �C�6�ntr �f r the ant M _ ori+ Dspme nes to 1--"d 33113% t f� Be artm Due 6 �-- EM. titan �� sA� •. Est. Comp. L� ' r f t $ SMfurity Intoes, YES 0 NO The Owner who tows M sMN be the obtipaUon W Me None Improvement Corttredrx to obtain malt permits as the Owner's AgOnt, gran ,Ind provisions el dbk own contuuctim•rNeteq Per it. a deal .A .++wapistered rsc�o�s _� be erduded from IM yu b M=. 142A. $" {t `t . 4t r -, tilt[. Z / /( f 'c• r r f/. / - /G'. 'j r" AN Home Improvemom Conue�tora and Subcomrsaws shelf be registered by the D❑ecter a 1 only fnquirlN abort e)ronusctOr rx Subcontractor reloung to a roglflretion should bli dreaed to: `•.\ F oil%o 11 A tj 15 P N 5 � tAreda � f /ruc-•��. 1C� S✓ rf'r .J n CyiS / S r✓ ✓c Home Improvemem Contractor Registration One Aahburion Piece, Room 1301 s ; !� &.0j. 4 r. 8wtan MA 02100 �1r !�'F �j�/+r, �N'•(I Lp'/.f� .817)727.630 pvte-f r/L1 111 THE OWNER SHALL PAY FOR THE WORK BY TME FOLLOWING METHOD: CASH UPONCOA4PLETION ( I SYMODERNIL1TtON LOAN (I A U�fele V . CorriradOr 11 the tv►me ovrMr Is t4ahv tats wkv 0ocaptena of this contras by the COMfada, def contrad shelf be rancelable by WUM to finance d» payment M (his work gtrough on smaN shed 1101114 Of ~ financial inattkdlon within fifteen (18) days. M work peAormeq by the CortrecW is k*y covered by Workmen's Compensation and liability, 1011 rame. NOTICE TO THE OWNS a4l�it. tom�e t tsti, Ned -In COW o, N11 amgnnaemirgk Modemi2alwn Leon in coder to enebk yes+ to Pay for said Impevsmenu. You Tors agleam coelqutea the antra gasment Of the partes and no other agrn Psrgss eregort a deviatiots. representations "Of n On 0116 need tit wood, shall be bindno on Miler psM herato urde%e in wn1Mg am slpned by wrlden Order and wit be Noted above HtvphAnp .off, costs o1 mabrNs a labor wlI1 be turrishad Ntd performedopecift"ons arty Wen I"0001" team Cost prim of etb Cadred TIM UMW W hWgW Wfffff ( ) t o he has May hive d this � we leans std carrriMiofls and M0 mtteni^g thereof hew be000W I* him pwn) and he (they) fully TM Ownar(s) odcnowbdpN de reeNp► of an eaeaAed copy of IMs AgfeemeM at the time of eseeutlon hereof. a art praMdem of tits ag►eemeR err (n eenMrA endedretie to ft any%'crate. ragulMiOn, r remWanancs or rufe of low. "n such provisiol» ehOM be deemvold .alert two" may Conflict owswo. bel 11;; 6W1dMind eraining provisions hweof. rsrdses Its workmanship kill \ years. R win'Whilm dsi1110" rnele'dal COMPANY'S GUARANTEE: The company I>v l Wolin do period d Www"s tin 91 Charge- AN m*MW for servlet must be In wNgngl .: Thi% sgrownere may be Cenmited by et of w of" woe am. 4A only withi t lh(ee (3) busfrtas dqe from the date of eeecunal and In a ownllr m~ of to Owner(s) fwd of Cyto l adore You raft sansei V" Aroma" tt llp m ul my loblIlty to test. Prevl W tltM you send a"ma . pa a 10 ld HM Co11lbeM, O til► ff Adnl jN Malts 0" ottalrlsas der kNawMO hour elOrdrq 010" AgreealOtK, by ordktcty mM', pefNd, by M.preset, err sent by dcNvcrlir WITNESS our hda and $"a tri. �dsy of1'��i,.= 200 m AMERICAN HOME BUI=RS M. M0101 SIGN THIS AGMEMENT 81FOM YOU READ (bl18JECT TO NOME �rCE APPROVAL) /�!f 011 V tNER�L`]f ARE ANY'MNK NACIS Ipepeweeeny . ACoeplod err• v Wawri><esdse.4 of 406VO24419 sNaa 1IIla 3WOH Nv3I21ziwv Wd £0: ZT S0-0Z—d3S ISWt OAn (kWDh*O 7/18/ 5 PROMM.. ... ... ..... .. .. .NL. .... .. . .... . THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION OY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Professional Risk Management DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE 1171 Washington St POLICIES BELOW.. West Newton, KA 02165 COMPANIES AFFORDING COVERAGE ITER A Scottsdale Ins. Co. ..................................... ................. ...... ...................... ......... `COMPANY B AIG American Home Assurance Co mum LMER American Home Builders, Inc. COMPANY c 46 Austin Street LETTER Newtonville, KA 02460D LETTER COMPANY E LETTER THIS 13 TO CERTIFY THAT THE PWCIFS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO -_­ " * .... * ........... .. .. .. ................ TIRE INSURED NAMED ABOVE ron THE Poticy PERIOD INDICATM, NOTWITHSTANDING ANY RECIUMEMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W1714 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY Pf!HfAIN, THE INSURANCE AFFORDED By THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS -UMO.N.S..M.D,.CO.N.DITIO.NS.O.F..�SUC.H.. POLICIES.... LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ................. I ...... . co ILYI: TYPE OF 911URANN POLICY NUMBER POLICY UMWN POLICY EXPIRATION! 11.01M DATE (WMD/rf) DATE (MMA313" ......... ... ..... .......... . . ...... ................. .... A.:.GDWAL Umm" GENERAL AGGREGATE P 2,000,000 X COWEACK ODOM LWKRV Pofty f:CLS091208? �­:, .:.. - — ........... . . PR0CL)CTSt4MP&* Aft s ,..2, .. ........ .......... 2,000,000 CLAIMS MAN x �M ........ ......... .03/25/05 03/25/ 06: P8-r7.mA.L--4_ADv-..wffly1, GOO.00Q OWNERS A CONTRACTORS PROT. EACH OCCURRENCE:8 1, 000, 00C ......... . .... ..... . ...... ....................... FIRE DAMAGE (Arty me firej S ....... .. ........ 50,000 .... . ....... ......... . .... MED. L)ftNSE y" ons gown) S . . .......... 5,000 COMBINED Sim" ANY AUTO LIMIT S AL OV44ED AUTOG BODILY RJURY .......... t SCHEDULED AUTOS (Pal person) HIED AM BODILY KAIRY N&J-01111HED AUTOS (Pat 8=UV) GARAGE LWKM ... ... ................. ........... .... . .. .... . ........... . .. ... .... PROPERTY DAMAGE EKC= UABILITY ........... :EACH,.OCCURRENCE .......... FORM......................................... .. ..... ......... AG DATE OTHER THAH UMBFIEUA FORM ........................... ............................. .................... ............................................... .................. CONIIIIIIIIIIIIIIAMN B . .......................................... .............. ........... ....... . X STATUTORY LIMITS .... .. ...... ........ ... sr 17/02/05 07/ 03./ 06 EACA.ACCIMT .......... ... ......... 500,00 EMPLOYE, LIABILITY .... ..... .................. .. DISEASE - POLICY LIMIT ........................... 500,000 ............ .... .......... .................. ................ ........................ ............ DkSEASE - FA04 EMPLOYM ............ ......... ................. ............. 500,000 A.Property Policy *:CLS0912007 `03/25/05 03/25/06. BPP 25,000 OEBCR/IpN OP OPOIAT10NiRACATIONWFI11CLi9l8P[CIAL RBA{....................... .. . . .................. .. ........... .............................. ... ...... . ... . . ....... . SHOULD ANY or THE ASM DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THFRFOF, THE ISSUING COMPANY WILL ENDEAVOR To MAIL - 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO MAIL SUCH NOTIC5rSHALL IMPOSE NO OBLIGAJION On LIABILITY OF ANY K�� THE CO"NY. 113 AGENTS OR REPRESENTATIVES. IT" T 0 d L06V024 L T 9 sN30:1i -, n . . a 3W : OH NV31N . 3WO wv ss:oT so—oz—inr O 7 a G YJ A rnmmc Cr- c� o <Zr-Z FCAO= t- -1 fn O m rn� D Z pp OES N C O 406 F A. t9 fn 'O y h� b� a . � uj o� i{3 0 ,I. 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 at: ' :z `� O oRe,! I`" s�` is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: Fire Department Sign off: Dumpster Permit (Location of Facility) Signature of Permit Applicant '-'z/ -oS� Date