HomeMy WebLinkAboutMiscellaneous - 39 AVERY PARK DRIVE 4/30/2018Location lo42)7C *31� ,/Y Ut'/ Acr 2)x
No. 3 Q 3 Date 1 —3 /- Da
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ 1-r0
Building/Frame Permit Fee $
Foundation Permit Fee $ p 0
Other Permit Fee $
TOTAL $
Check # 7 /Z!
15295 Building Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
IBUELDI
MI
G PERT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/In ctor of Buildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address: ' 0 7—.1 7G
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
1.3 Zoning Information:
RA
Zoning District Pr osed'fJse
1.4 Property Dimensions:
9,
Lot Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide Required Provided
Rewired
Provided
3(f) -7 5-'
1.7 Water Supply M.G.L.C.40. Sj 54) 1.5. Flood Zone Information:
Public Private ❑' Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
s, fife '300
Name (Prin Address for Service:
��Z, 6 $
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Tele hone
SECTION 3% CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
%Oo O -L/ ' OS5 Sfe 7 e20
Address46 Lzz,( 67 —. <3C)o
Signature Telephone
evr"7�P
Not Applicable ❑
Cry C:6y .23
License Number
��
all
Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Tele hone
M
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X
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1
0
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90
0
ic
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SECTION 4 - WORI{ERS COMPENSATION (M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes ...... No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify
Brief Description of Proposed Work: > l
a 6 �y 00 ('977i i L u''/ el (l ed /i' yi&- s, 02 1 6,914
'r- . y e- r J N-( to r / 6 K ram 6 i'02 -an 3 X 1:?
'P—W �-ra,"e --1 /,2 X/6 We)ac( `.mrd G/ea-re
I SECTION 6 - FSTYMATF.11 C0N1qTRTTCT1nN Cn.vTS I
will result
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
O t5 -D O
(a) Building Permit Fee
Multiplier
jo . S0 t "o on
2 Electrical
(b) Estimated Total Cost of
Construction
c;216
3 Plumbing
Building Permit fee (a) X (b)
L/'S
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number
SEUl'IUIN 7a UWiNER AU 111ORIZAllUIN "1'0 13E COMPLE'lED WHEN
OWNERS AGENT OR CONTRACTOR 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 application.
Sig -nature of Owner Date
SECTION 77b OWNER/7a
AGENT DECLARATION
I, lc / �-�5 s l as Gm w/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 K
Print
of
i
Date
NO. OF STORIES SIZE 6z(o x(o
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 sr ' " 2 ti- a- 3
SPAN
DIMENSIONS OF SILLS 6
DIMENSIONS OF POSTS re 'V-e'o
DIMENSIONS OF GIRDERS
I-IEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING "o X 2,0
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE :.101,P�
N e- w 6", vwe---
FORM U - LOT RELEASE FORM (_ Cl 0 a,
INSTRUCTIONS: This `crm 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 or requirements.
*************************APPLICANT FILLS OUT THIS SFCTION�*�**~�*tit
y��e1t Ss '7-6760
APPLICANTCYC je� �'o��Sf e PHONE Gg7-63oc�
LOCATION: Assessor's iU1ap Number PARCEL
SUBDIVISION 0-2ogOA�11 LOT (S) 0l 7 0-
STREET UPY�.' /��-✓% Y" ST. NUMBER
* t k******* t*** k********
OFFICIAL USE ONLY***t*****t********* t t k k***********
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION AD NISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
T PLANNER DATE APPROVED -ZZ Z,
DATE REJECTED
COMMENTS
FOOD INSP TOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
w
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT,
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
The .Commonwealth of Massachusetts
Department of Industrial Accidents
Offic-a of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
Name:
Location:
City Phone #
I am a homeowner performing all work myself.
aI 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.
Companv name %Dn�iic9�i� / 2Sf Gt �'Si f i G'�✓;
Address /00 s�?c"��D ;P- S/V,—va-5'_s" SO
City /Vo!`f1/✓ /d'���oyZ�' "l c? ��i°5` Phone -#* �9� � 7 y s 30Q
Insurance Co.. 6 n . Policv # Ku C-1_ O
Comoanv name:
Address
Cit/' Phone #:
Insurance Co Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00
and/or one years' imprisonment as well as c' nalties in the form of a STOP WORK ORDER and a fine cf ($100.00) a day against me. I
understand that a copy of this statement 7fay be foNqrded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify undgr the
Signature
Print name
�ery
that the information provided above is true and correct. /
Date l 2
n4
Phone # 5-3—.7" -7 7( p
Official use only do not write in this area to be completed by city or town cincial'
City or Town P=rmit/Licensina
Building Dept
r-1 Check if immediate response is required ❑ licensing Board
❑ Selectman's Office
Contact person: Phone #: ❑ Health Department
❑ Other
Growth Manaaement 8yiaw Exemption Statement
Town of North Andover Building Department
T'nis form shall be used to assist the Building Oepartment in their determination of exemptions under section 8.7.6 of the
Town of,North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary information
as requested 'below.
Name of Applicant an BLuilding Permit (below) Address of Property Per Pemlit (below)
Mao and Parcel :,"466 Purpose of Application (check below)
Phone Number of Applicant: Single Family Two Family
I the undersigned applicant for the above property attest that the attached building pem;it for which this
form is compieted does comply with the EXEMPTION section 8.7.6 of the North Andover Growth
Management Bylaw. I also understand providing this farm does not absolve me or acv parry to this permit
from the requirements of abtaining other permits required prior to the issuance of the 5uiiding Permit.
Further I understand that my interpretation of the E:<ENIPTiON status is subject, to review by the Building
Department and is only officially accepted when the Building Permit irk issued.
Based an section 8.7.6 of the North Andover Growth Bylaw the above [at and the work as applied for on the
above lot, in the building permit application and associated attachments, complies with one or more of the
following sections as indicated by a check mark.
This is an application for a building permit for the enlargement. restoration, or reconstruction of a dwelling in
existence as of the effective date of this by-law, provided that no additional residential unit is created.
ZymaThe lat(s) werelwas seated prior to May 6, 1996 are exempt from the provisions of this Secticn 8.7 of the Zoning
W
This application is for dwelling units for low and/or moderate income families or individuals, where all of the
ccnaitions of 8.7.6.care met and/or represents Oweliing units for senior residents, where occupancy of the units is
restricted to senior persons through a property executed and recorded deed restriction running with the land. For
purposes of this Section "senior' shall mean persons over the age of 55.
�I
This application is a part of a development project which voluntarily agreed to a minimum 40% permanent
reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the
environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently
designated as open space and/or farmland. The land to be preserved shall be pratected from development by an
Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism
approved by the Planning Board that will ensure its protection.
This application represents a tract of land existing and not held by a Developer in common ownership with an
adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth
Rate and Development Scheduling provisions far the purpose of constructing one single family dwelling unit an the
parcel,
This application represents a lot which is ready far building permits,(i.e. all other permits from all other boards and
commissions have been received and the project is in compliance with those permits), and the Oevelcpment Schedule
does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per
(Development until such time as the Oevelopment Schedule accommodates issuing building permits. Applicant must
supply approved form U with this EXEMPTION.
Please provide any and all information that would assist the Building Department in making a determination
that your application is allowed one or more of the above EXEMPTIONS,
By signing below I attest to c' uraey of the information provided and that the attached building permit is
allowed an EXEMPTION s cited ave. Further I understand that the submittal of misleading and or
inaccurate information, r the checkm g off of an above item which does not comply, whether done to my
knowledge �iot, is g unds for re' at by the Building Oepartment to issue a Building Permit.
Signature of Owner a4 A4onzI_-q±9eaVWno signed the Attac, ed Building Permit Oate
This form must be a shed to the Building Permit upon application for such permit.
BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
In accordance with the pmvisions of MGL c 40 S 54, a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in a property licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in:
J) U122,2 -A41<1 "q Sao - - A
Location of Facility
Sie oYPermit Applicant
LSO
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of
the Building Inspector
FORM J
LOT RELEASE
The undersigned, being a majority of the Planning Board of the Town
of North Andover, Massachusetts, hereby certify that:
a. The requirements for the construction of ways and municipal
services called for the Performance Bond or Surety and dated
Dec,}W , 19 (Ic_ and/or by the Covenant dated
Ma,v a9 19 _3 and recorded in District Deeds,
Book Page -lag or registered in
Land Registry District as Document
No. and noted on Certificate of Title No.
in Registration BookPage
has been completed/partially completed,�to the
satisfaction of the Planning Board to adequately serve the
enumerated lots shown on Plan entitled ++ C4rn e.11 fe r f-54
$ PIqA1 Section (s) Sheets
Pian dated.eMI19 recorded by the ESSEX
North D istrf cT egistry of Deeds, Plan Bookor
registered in said Land Registry District, Plan Book
Plan -*/a7 81-f , and said lots are hereby released from the
restriction as to sale and building specified thereon.
Lo{�
Lots designated on said Plan as follows: (Lot Number (s) and
street(s))
b. (To be attested by a Registered Land Surveyor) Lo'rS
L Ors 17 -pa-.. l s ; LoTS
I`` hereby certify that lot number (s) 1.0n.., ZS 77+2v 37-1 &A
Vo�N�+: 17+uyaf Ca�c,. w sc�n�. W00o'w C,,,,,� tao.�Ni. �n���r Street (s)
conform to layout as shown on Definitive Plan entitled
it
�P��yC&F' Section Sheet (s)
2�,ZS f Z'1
on
do
OF MRS�q
ALBERT TZE
G�
TRUOEL N 4Rg4lstered EL
Q N0.36869 0
a
rFss/ NfCISTc,
1 of 2
C. The Town of North Andover, a municipal corporation situated in
the County of Essex, Commonwealth of Massachusetts, acting by
its duly organized Planning Board, holder of a Performance
Bond or Surety dated , 19 and/or
Covenant dated 19 from
of the City/Town of
County, Massachusetts recorded with
the District Deeds, Book Page
or registered in Land Registry District as Document No.
and noted on Certificate of Title No. in
Registration Book, Pageacknowledges
satisfaction of the terms thereof and hereby releases its
right, title and interest in the lots designated on said plan
as follows:
EXECUTED as a sealed instrument this S day of Ott 19
. L L[__
Majority of the
Planning Board
of the Town of
North Andover
COMMONWEALTH OF MASSACHUSETTS
Es5-e-x , ss
Dere;� bar Z1, 19 q5
Then personally appeared6a; cqt d , one of the above
members of the Planning Board of the Town of North Andover,
Massachusetts and acknowledged the foregoing instrument to be the
free act and deed of said Planning Board, before me.
Notary Pkiblic
My Comm.issi n Expires
2 of 2
1128
APPLICATION FOR WATER SERVICE CONNECTION
North Andover, Mass.
Application by the undersigned is hereby made to connect with the town water main in
subject to the rules and regulations of the Division of Public Works.
The premises are known as No.
or subdivision lot no.
Owner
Contractor
I
ver
Address
Address
pplicant's Signature
PERMIT TO CONNECT WITH WATE
Street,
Street
The Board of Public Works hereby grants permission tovl/'/' 1t I-0'- &-z t
D`�
to make a connection with the water main at f 11/1'. �//1 / �frStreet
subject to the rules and regulations of the Division of Public Works. f/
Board of Public Works
By r�
Inspected by
Date
See back for rules and regulations
1755
APPLICATION FOR SEWER SERVICE CONNECTION
2�
North Andover, Mass.]2zc-.z 7-�-�''
Application by the undersigned is hereby made to connect with the town sewer main in Avat,�— Street,
subject to the rules and regulations of the Division of Public Works.
.n
The premises are known as No.
61-l'? Kir P/.
or subdivision lot no. Z
LLC [po Azmev- 8r, pa�'5':2
Owner Address
Contractor
PERMIT TO CONNECT
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at /—
subject to the rules and regulations of the Division of Public Works..
Inspected by
Date
Address
pplicant's Signa
SEWER MAIN
Street
Street
Division of Pu is Works
By
(7,zi),AW-
See back for rules and regulations
J.WILLIAMHMURCIAK, P.E.
DIRECTOR
TOWN OF NORTH ANDOVER, MASSACHUSETTS
DIVISION OF PUBLIC WORKS
384 OSGOOD STREET, 01845
NORM
t -o
X
DRIVEWAY PERMIT
Telephone (978) 685-09SG
Fax (978) 688-9573
DATE
LOCATIONA)e'f L'f/( 27c
BUILDER hone
OWNERC®edj c' phone
THE NORTH ANDOVER SUPERINTENDENT OF OPERATIONS
MUST BE NOTIFIED OF THE GRADE AND SETBACK FROM
STREET. CALL THE SUPERINTENDENT'S OFFICE BEFORE
FINISH GRADING AND SURFACING FOR APPROVAL OF
SUCH ENTRY.
FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT.
A�c-� CAN
y� ✓�ie TDanvrrearuaeaC�i a�✓�acsucde�`6
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
1
Number: CS 069234 i
' Birthdate: 05/09/1954
Expires: 05/09/2002 Tr. no: 23903
Restricted To: 00
ALAN G RUSSELL _
400 MAIN STe
GROVELAND, MA 01834 Administrator
i
Building Value Calculation -for Property at..... LOT#27c
Room
Length
Width
Sq.Ft.
Cost per Sq.Ft.
Total Cost
Kitchen
24.5
13
318.50
65
$
20,702.50
Brkfstnook
11
4
44.00
65
$
2,860.00
Dining Room
15
13
195.00
65
$
12,675.00
Family Room
22
16
352.00
.65
$
22,880.00
study/office
-
65
$
-
Living roam
-
65
$
-
Garage
24
22
528.00
65
$
34,320.00
Entry
15
13
195.00
65
$
12,675.00
2nd floor foyer/sitting
11.5
10
115.00
65
$
7,475.00
Sunroom
-
65
$
-
mudroom
-
65
$
-
Walkin closet
9
9
81.00
65
$
5,265.00
Basement Finished
-
65
$
-
Balcony
-
65
$
-
Screened Porch
-
35
$
-
laundry
13
7
91.00
65
$
5,915.00
Bedroom 1
22
16
352.00
65
$
22,880.00
Bedroom 2
13
17
221.00
65
$
14,365.00
Bedroom 3
15.5
13
201.50
65
$
13,097.50
Bedroom 4
15
22
330.00
65
$
21,450.00
Lav / Bar
-
65
$
-
Bathroom
13
8
104.00
65
$
6,760.00
1/2 Bath
13
6
78.00
65
$
5,070.00
Bathroom 2
13
9
117.00
65
$
7,605.00
Bathroom
-
65
$
-
Deck
13
3
39.00
10
$
390.00
Balcony
-
65
$
-
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Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,2
This certifies that ........................7.....y...... ...........................................................
has permission to perform -.................................. 2� ..........................................
.
wiring in the building of .... ..........................
at .... . ............✓. .......... � . North Andover, Mass.
..............
2
Fee..�`.- ........ Lic. No . ............. ........ ............... ...................
Check # r2 Ze -.a-- 4��/ �—EucrmcAL INSPECTOR
THEC0AW0 TffEALTHOFAWSACHUSETTS Office Use only
DEPAIZTA N 0FP1MIICSAFEIY
BOAROOFFIREPREVENI7ONREGUMHONS527CJM12.'(XI Permit No.
Occupancy & Fees Checked
APPLICATIONFOR PERMIT TO PERFORMELECTRICAL WORK
ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 52'7 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
.Town of North Andover ,�
To the In pectoi'of Wires:
The undersigned applies for a permit to perform the electrical work described below.
Location (Street &Number) / U� �`� ; 7— C
Owner or Tenant,,
Owner's Address -,� ./Ji��, /'�o.•� r it . �_
Is this permit in conjunction with a building permit: U Yes
Purpose of Building
Existing Service �� Amps /v Volts
New Service ,GIiG�� Amps olts
Number of Feeders and Ampacity�, �T-
Location and Nature of Proposed Electrical Work `,., a f
No. of Lighting Outlets �2
No. of Lighting Fixtures
No. of Receptacle Outlets
No. of Switch Ovitiets q
No. of Ranges /
No. of Disposes
No. of Dishwashers /
No. of Dryers J
No. of Water Heaters / KW
C� �S
No. Hydro Massage Tubs /
OTHER-
No. of Hot Tubs
Swimming Pool Above
No. of Oil Burners
YNo (Check Appropriate Box) U
Utility Authorization No 1lZ Z 6
Overhead M Underground ED No. of Meters
Overhead Underground ®/ No. of Meters
No. of Transformers Total
Below KVA
Generators KVA
round
No. of Emergency Lighting Battery Units
No. of Gas Burners
2
No. of Air Cond.
Total
/
FIRE ALARMS
Tons
6
No. of Heat
Total
Total
No. of Detection and
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Tons
KW
Initiating Devices
Space Area Heating
KW
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Heating Devices
Local Municipal
No. of
E
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ns
No. of Motors
Total HP
No. of Zones
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Telephone No. PERMIT FEE
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(REGISTEROF ELECTRICIANS
ED MASTERiELECTR I C I A N .
ISSUES THIS LICENSE TO
MARK A NIEMI
60 ESSEX STREET
jLOWELL�
MA, -01850-1129 1�1
15839 A 07/31/04 342185
mmmm• _
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Location 0..
No. �" % Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame /Frame Permit Fee $ /? Z
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Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # 16 �7
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NO. �fi889 �
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BLOT 27c Bas
;;AVERY PARK DRIVE
NORTH ANDOVER, MA.
!iPREPARED FOR:
;JANDOVE:R BUILDERS
16 MULBERRY CIRCLE
{ANDOVER, MA. 01810
A
DATE: SEPTEMBER 6, 2002
ISCA1..E. ," m 60'
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1 HEREBY CERTIFY TO TOWN OF NORTH
ANDOVER,
MEA BUILDING DEPARTMENT
TIA'J'
f[IL 'EXISTING FOUNDATION
i)Rj d&N ON
T1113 PLAN 4� LOCATED AS.
SHOWN AND
THAT IT DOES COMPLY TO
THE 611NIMUM BUILDING SETBACKS 1'0
PROPERTY LINES.
Of HOR7M ,M
O 9
SSACHUSE�
Date .f .- . O oZ
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
l V�1�c�ati�ca
This certifies that .. .. .
has perrr� fission to perform ..'V f- 0p /�
plumbing in the buildings of . N.0
,NDUrR ` io r S
at .vim.% ... N. v{r `�...A .e... �.� ... , No h Andover, Mass.
�a..� �.�t'fc�.—
Fee. . :y y�.. Lic. No. o2 2
... .. .......... .
PLUMB G INSPECTOR
Check # X0-3
5404
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date /0 _ Ay
Building Location 3 Owners Name",,y W1 Permit #
Amount
Type of Occupancy J� r
New ® Renovation 1:1 Replacement 1:1 Plans Submitted Yes [a— No 11
(Print or type)
Installing Company Name
Address
zD w1
Check one: Certificate
B—C—Orp.
Partner.
Firm/Co.
Name of Licensed Plumber: �N �� +.u� (p , I 1 "—
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy I..�T Other type of indemnity ❑ Bond ❑ .
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeance P A
Signature Owner Agent ❑
I hereby certify that ala 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 Massachuselta.We Plumbing Code&d Chapter 142 of the General Laws.
By: Sig,iaiure vi�Lic ensea riumoer .
Title Type of Plumbing License
City/Town icense Numoer Master Journeyman ❑
APPROVED (OFFICE USE ONLY
/
•
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G
/
Irl
•r
'
/
_
Cl��--��----------------
mmmm
(Print or type)
Installing Company Name
Address
zD w1
Check one: Certificate
B—C—Orp.
Partner.
Firm/Co.
Name of Licensed Plumber: �N �� +.u� (p , I 1 "—
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy I..�T Other type of indemnity ❑ Bond ❑ .
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeance P A
Signature Owner Agent ❑
I hereby certify that ala 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 Massachuselta.We Plumbing Code&d Chapter 142 of the General Laws.
By: Sig,iaiure vi�Lic ensea riumoer .
Title Type of Plumbing License
City/Town icense Numoer Master Journeyman ❑
APPROVED (OFFICE USE ONLY
Date. .40 -) 5 .7.
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .................................
has Permission for gas installation h f �j? ... 0.1m .`.C...... .
in the buildings of AJ010 U '(d f,
at Ct ... tC ....... North Andover, Mass.
Fee..95.. Lic. No/'.7W�..
GAS INSP CTOR
Check #
4165
MASSACHUSEM UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations 3 y A Vc- c!A Pei YL
_S__Owner's Name
Date / o - /,Y - A ap"n-
New' 11- Renovation [] Replacement [] Plans Submitted [a,,-
(Print
a/
Permit #
Amount $
(Print or type)--
Name
ype
Name of Licensed Plumber or Gas Fitter
srtificate Installing Company
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes NoO
If you have checked M .please indicate the type coverage by checking the appropriate box.
Liability insurance policy [2/ Other type of indemnity E] Bond 0
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. eral Laws, d that y signature on this permit application waives this requirement.
/G►� L�� Check one:
Signature of Owner or Owner's Agent 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 Massachu=M State Gas Code andhapter 142 of the General Laws.
ICity/Town
(OFFICE USE ONLY)
Si ature of Licensed Plumber Or Gas Fitter
Plumber / ?a-7 q
0 GasFitter License Nurn er
aaAaster
Journeyman