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HomeMy WebLinkAboutMiscellaneous - 40 HITCHING POST ROAD 4/30/2018 / 40 HITCHING POST ROAD 210/065.0-0277-0000.0 �1 II it 1 ' 1 l Date........................................... OF NOwTN,� 3�; ;•. ao� TOWN OF NORTH ANDOVER o n PERMIT FOR WIRING �,SSACHU�t�g Thiscertifies that ........................................... ... ....................................... has permission to perform ........�..............................................................�'oS ......................... wiring in the building of......+.....P.S..S `�5 ................................................................................... at ...A).....-.. 1'� o���............p.. ..d...E...C... .R.INorth Andover,MS. , .. . � f Y�Fee... .. ...... . . ....... b li: TANETo Check# N Commonwealth of Massachusetts q�i'l Use Only Department of Fire Services Permit No. 1 � Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 3--/7-� City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �—/10 Z71_/TC/-11446 ;7- Owner or Tenant .LL-A4L Cin/D Y /��SS/N S Telephone No. Owner's Address S F3 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 7f:>W CZ41-1e> Utility Authorization No. Existing Service 1,00 Amps O Volts Overhead ❑ Undgrd No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: oa76r,.rs /— Completion Com letion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires 3 No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA Q No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones d No.of Switches / No.of Gas Burners No.of Detection and Initiating Devices _ No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained Totals I ................... ........................ Detection/Alerting Devices Municipal `n No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) r Work to Start: �--17-/< Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 Covera a is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: ELECTrLlG LIC.NO.:4 3 Licensee-7A-Z/4,4--T S/��C��✓(1'>�piL/> Signature LIC.NCC-,3 S (Ifapplicable,enter "exem t"in the license number line. Bus.Tel.No..• Address: /58 �7anlLQ,/Zt�G� ��. jD2<FC�f7. t �82� Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does 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 a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. f The Commonwealth of Massachusetts Department of IndustrialAccidents a ; - 1 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. Applicant Information Please Print Leiribly Name (Business/Organization/Individual), Address: '�� t`1�`1 P667� City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. am a sole proprietor or partnership and have no employees working for me in $./ ',Remodeling /any capacity.[No workers'comp.insurance required.] El D 9.. El Demolition 3. 1 am a homeowner doing all work m o workerscomp.insurance required.]❑ g self.� 'Y P q 1 t 10❑Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.F1 We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: C Policy#or Self-ins.Lic.#: (J 8S�✓"l ( L��7 Expiration Date: S Job Site Address: City/State/Zip: G✓met- , Attach a copy of the workers' compensation policy declaration 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 her he pa n and penalti perjufy that the information provided above is true and correct. Sienature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions �H 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 of 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-contractors)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 city or 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 tocontact 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 v COMMONW ACTH OF MA"A"USETTS BOARD OF ELI:GTRICIAl S ISSUES THE FOLLOWINGLfCENSE.;: A5 A REG JOURNEYMAN ELECTR,I C IRAN:: THOMgS J SPRINGFORD 158 STONERIDGC j DBACUT MA o1826-26 34145 >=!. . 07/3l/16 39125 O < OMMONWEALTH OF MASSACHUSETTS • • ; oTmgmrsillm BS?AW 6 R AN I' SUES THE FOLLOWING LICENSE AS Al. i. f2f G l RED MASTER. E:L E CTR C-I-AN I¢ ` i TH0Ml5 J SPRING FflRD w��r ! It 158 STON.El3R ruG DRACUT. MA 01826-2660 20336`'a<»>><''0 /3 /1:_6=:; :: 39124 f Crawford CRAWFORD AND COMPANY 1001 SUMMIT BLVD ATLANTA, GEORGIA 30319 RAY CALVETTI 830-734-0235 ray_calvefti@us.crawco.com 4/8/2015 'Town of North Andover 1600 Osgood St North Andover, MA 01845 Re: Insured: KARL J PESSINIS and CYNTHIA A PESSINIS Claim Number: KAWH31 Policy Number: WY8304 Our File: 6776-2590586 Date of Loss: 2/20/2015 Type of Loss: Weight of Ice &Snow Location of Loss: 40 HITCHINGPOST RD NORTH ANDOVER, MA 01845 Insurance Company: Mapfre Insurance To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property,which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6,to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, Ray Calvetti Claim Representative CC: North Andover Inspector of Buildings Date.4 ff// ...... n iI ;' � of".SRT TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING A CMUSE / /'� This certifies that...� ./. ' ! " has permission to perform......! j�.... -- s� -Q................................ plumbing in the buildings of...F....��.S s .......................................................................... t 4 le-/, �as�................................. North Andover, Mass. at......................................`--/ /, ........................ Fee..7a..� .....Lic. No./d tp... ./1,�-�— ................................................................................ �, PLUMBING INSPECTOR Check# -A f-q 7 _ MASSACr USETTS ' UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUf�hBING VifORfK `44V I CITY" • i' MA. DATE ' i JOBS(TEADDRESS �jQ�o�S� IPEP,M17;1�G OWNER'S NAME OWNER ADDRESS: i TYPE OR I OCCUPANCY TYPE TEL K_�3 PRINT X:(�--- COMMiERClAL❑ cCUCATIOt\AL T L-� CLEARLY -„� _ ❑ RESIDENT IAL ®` ! i NE l ❑ RENu,'A!ION: I ❑ REPLACEMENT I, ,• FIXUTRES - PLANS SUBMITTED: YES❑ NO❑ FLOORS-� i E35mi ! 1 i 2 i 3 ! 4 ( ._ BATHTUB CI ROSS CONN DEIi!CE 13 I 14 ( DEDICA!ED SPFCI;L Irl'ASTE SYS I ( I J i I I ' DEDiCA i ED GA�rOIL'S.4tJD SYS L DEDICATED GREASE SYSTEM DEDICA T ED GRAY INA ATER SYS I I I I 1 I I I DEDICATED WATER REUSE SYS DISHWASHER I J DRINKING FOUNT,AII\l I I `OOD 4N,gSTr GRINDER UNIT IT I rLOOR,' ,RCA DRAIN - i I _ j i ! 1N TCH T ERCEPTOR INTERIOR KIEN 6INK LAVATORY I I I ( ROOF DRAIN I SHOINER STAL SERVICE�MOF SItdK - ' ) J i I TOILET URINAL 1NASHLNG rvLgCHlr\IE ONNEC-IOIJ WATER HEATER ALL vUATER PIPING I ' ' I i I I I ff I i l have e current liabilify insuran;;e � I INSURANCE COVERAGE III policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES �O ❑ I 3— If you have checked}'ES i __ please indicate;he h'Pe of coverage by checking thea f I appropriate box below, �----- LIABILITY INSURANCE:POLICY OTHER TYPE INDEMNITY ❑ BOND OWNWR'S INSURANCE WAIVER:I am awa-e that the licensee Does not the insurance coverage required by Chapter❑zr 142 ofthe Massachusetts General Laws; and that my s _!nature on this permit application waives this requirement. j SIGMA I URE OF OV+JN�P OR AG�rJT -�-- CHECK ONE ONLY: OWNER ❑ AGENT 1-7 Ihereby cerfifv that alt of the details and informaiior, i hav Knowledge and that aft plu.mbin wort;arid e submitted("or entered)regarding this applicati ue and i provision of the Massachus=tts 9 tate Plumbing d ins_I ations performed under the permit issued for this a accurate to the best of my mbine Ccde and Chapte 1q2 of the Genera!Laws. p anon wi e in complian with at)Peri PLUMBER t\1AfVjE: i gT 1 LICENSE= �8a coMFAn'Y tvAt,+iE j L - SIGNATURE I R► IAV } }� i ADDRESS: � _R 1A ti Q R 1 CITY _ L•r' —� SIATE: Y� 'lvI l TEL: —79�i'- I FAX: v' EMAIL: RT v MASTER JOURNEYMAN!_ � r— /)7 :C;„ ORATION Z�)q—�� �i�= C_;PARTNERSHiF L;r I L #,. \` ❑_ _ \� ' I The Commonwealth of Massachusetts Department oflndustrialAccidents -- 1 Congress Street,Suite 100 Boston,J 02114-2017 V,V't www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Applicant Information Please Print LeLyibl Name (Business/Organization/Individual): Address: City/State/Zip: � ,�b(I 0079 Phone#: en-3 _,3 93 9,6 Are you an employer?Check the appropriate box: Type of project(required): 1.W.'m a employer with 3 , employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.FJI am a homeowner doing all work myself.[No workers'comp.insurance required.]t 1 ❑Demolition 10 ❑Building addition 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 11.❑Electrical repairs or additions proprietors with no employees. 12.EQYlumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit 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-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance CompanyName: 0A Policy#or Self ins. Lic.#: CP © Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the worke s' compensatiVGLc. olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 verific I do hereb certify nder the ains an Ities of perjury that the information provided above is true and correct. Si na e: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: t 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 of 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 city or 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-iii'sured'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.)saiderson is NOT required to complete this affidavit. P q P 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 f 1� COMMONWEALTH OF MASaACHUSE. i PCUMBERSBR LFITTER,S ISSUES THE EOLLOWIIG L,IDENSE LIGENSEQ` AS A MASTER PLUMBER:' it �• }r�,ri �Z PAUL E MARTIN ,t 7�� {Ow W ; i 6 MER 10 I Ate OR rF t` W SALEM NH 03079 411 J 12380 "05/0116 226077 Date... �, ... f �aORTH 3r;.�``°:•_�.."�o� TOWN OF NORTH ANDOVER awmifts PERMIT FOR WIRING �,SSACMUS� This certifies that ........... .......�GT ........................... has permission to perform ...... . 5 .. .....�7s�..��T ...... wiring in the building of.................: ./.. . ......................................... at.. O ,/�............ „ ,,,, ,North Andover,Mass. 11 Fee�C................... Lic.No....... .. ....... .. .! ....4 ..... LE CAL HECTOR 7 ( Check # 10668 AUJ./-I.p aenuseLubmiee icaoneAmppennments527CMR12.00§Rule 8: In accordance-with theprovisions of M.G.L.c.143,§.3L,the permit application form to provide notice of installation of wiring shall be uniforin throughout the Commonwealth,and applications shall be filed the rescribed form.After a ermit a hcation has been accepted by an Inspector of Wires appointed pursuant to M.aL c. 1663§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the otification of completion of the work as required in M.G L.c.I43,§3L. - - emzits shall be limited as to the time of ongoing consiruction.activity,and maybe deemed_by_the.I'nspector_of-Wires abandoned_and_invalidSf_he_. or she has determined that the authorized work has not.commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the.permit application. ❑ The Permit Extension Act was created by S, .3 , of Chapter 240 of the Acts of 2010 and extended by Sectipns.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to aote job;growth and long term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year a ension to certain-permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period be ' ' on Aupst 15,2008_and extending-through August 15,2012. X-Rnle 8—Permit/Date Closed:j / '�**Note•Reapply for new per ' ❑PermitExtension.A.ct—Permi ate Closed: I/ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co (M 'C),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: k 1 Z City or Town of: NORTH ANDOVER To the Ins ect r of Wires: By this application the undersigned gives notice of his r her i tgntion to perfo the electrical work described below. Location(Street&Number) �? / Owner or Tenant e / Telephone No. Owner's Address Is this permit in conjunction with a building p mit? Yes Ejel"'No ❑ (Check Appropriate Box) Purpose of Building 51 'Ide �.1 117 Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters 4 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wi t1 t n n i I Com le on of the ollowing table may be waived by the Inspector o Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Z Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] No.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets / No.of Oil Burners FIRE ALARMS No.of Zones No. of Switches Z No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "'"" Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWpp•� Local ElMunicipal ❑ Other OG/ Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent �a OTHER: – U _ U p Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 substant'/Ieuivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the rmi iss g office.CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 5 � ZI cert,under the pains a zal1. ofUrj,,ry,t zat the iuformati this application is tru anmplete. FIRM NAME: `J !� (� 1( LIC.NO.: Licensee: el-\ Signature LIC. NO.: (If applicable em n the h ense number line.) Bus.Tel.No.: Address: J v )(i �1'I Alt.Tel.No.: *Per M.G. r� Ik L c. 14 ,s. 57-61,security work quires Department of Public Safety"S"License: Lic.No. ' OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance cove e normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's Owner/Agent —7 PERMIT FEE: $ Signature Telephone No. 9302 Date. E r pORTM 3Za..A�•�.;.'�oot TOWN OF NORTH ANDOVER F � PERMIT FOR PLUMBING 40 k 2SACHUS s / r � J �i v� This certifies th'aR 1'. :. . . . . has permission to perform .�Z . .. . . .._ . .`r. . . . . . ... H. .4-•,.. plumbing in the buildings of e. SS. . .`. . s. . . . . . . . . . . . . . . . . at. YoL/u /Y*/ t r �' 6 5 . . . . . . . . . . . . . .�.� . . . . . . . . , N h ndover, Mass. Fee. . . . S. . . .Lie. No.. �1�. . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # s 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK. CITY ''i'I U I MA DATE.j Z,./7/ /L J PERMIT# JOBSITEADDRESS I qVf Cti/^� f i' v 7 OWNER'S NAME 1 /0 e SS I"v/ S OWNER ADDRESS I S 114.1 `e l TELT 4FAx I IE TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ( RESIDENTIAL.J L�/ PRINT CLEARLY NEW.(VI'*' RENOVATION:( ( REPLACEMENT: PLANS SUBMITTED: YES{ I NO( l FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 t4 BATHTUB - CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAYWATER SYSTEM DEDICATED WATER RECYCLE:SYSTEM y _ DISHWASHER i 1 DRINKINGFOUNTAIN '0 0 FOOD DISPOSER S FLOOR/AREA DRAIN u <- - INTERCEPTOR INTERIOR' KITCHEN SINK i LAVATORY ROOF DRAIN SHOWER STALL _ .._ SERVICE/MOP SINK TOILET URINAL -- ' - - --�— i '4 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - WATER PIPING URE—RI 1',v 6C i _ -- - - -- f IN'SURAN'CE COVERAGE- I have a cttrrent liability insurance otic or its substantial a uivalent v/hick meets the re uirements of MGL Ch.142. YES(�NO � P Y q q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVER'AGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY iNSURANCE POLICY( OTHER TYPE OF INDEMNITY( ( BOND I I OWNER'S INSURANCE WAIVER:I ain aware that the licensee does not have the insurance coverage required'by Chapter 142 of the Massaclttisetts General Laws,and that my signature on this pennit application waives this regi ireinent. CHECK-ONE ONLY: OWNER. AGENT ( I SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and WDrniation I have submilled or entered regarding this application arue and accurate to the be of my k.00VAedge and that all plumbing work and Installations perforated under the permit issued for this application will be in'6orhpri ge nth ali Pertinent 64sio the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �p- PLUMBER'S NAME S'l�-��`� A.i � Gf� ILICENSE#J ffV�( V GNATURE --- l MPI I JP 1 I CORPORAT*N'}vf? (V36 1PARTNERSHIPI ill; (LLC( 1#1 COMPANY NAME 12 . r S I}j-ci wr�,.� 2 �'d-!� ADDRESS 13 ,5>, ,S'�i y CITYhU ' yA NJ a✓.Lti. ISTATE Al ZIP �/ -I- TEL 3t i FAX 519 11-v CEaf Y r/S 3 S d EMAIL - t i l � J ROUGH PLUMBING INSPECTIONNOTES BELOW FOR OFFICE USE ONLY FINAL INECTION NOTES Yes P40SP THIS APPLICATION SERVES AS THE PERMIT `❑. ❑ FEE::$ PERMIT 0 PLAN R VIEW NOTES b r 4 4 3 F i !i i • llr��'iplttrtioaat��e�rlllt�►,�'lY��uc��rs¢ ', l?e�r7trr�at`o�'Ittrl�rs�!oltitecftt�iris _ ,, f�,j�fe�ir•J''firs��figR/r�nrs ifog f rashrAgran Sweet [ .kJpffoir,'11M.tRfff F IGtt'falta(rsxgat�lrt +'�torlivre .`FIHlJ�C11Sit�k01!' l!$ttL'}1t�� C([hitt'lj I i Ic cssfCau to o .3i a TrYcinitst'li tib l} �'fit�IferrflElilfort!laiiisi5 .T _ � ._ .: ..�'�e /prrilEZ;�`FC�� . �o[l���trsLt�fUighiiiiitio'n►luiiiEidual3� �,�!•:.. �lis "l..c��ii'�L'� p,,,�il�- l f� t A(Mress b 41) k S.—S 1-1 Oil l t ifef �-y,t.U ✓}-'���_______e_ 1)hoite l�: CL.. iF 'l s ;Ilrcy tc uei)rl�[ayxr2GkectcthcnpproptFnteGoy: T Ir�bfl)tofccsOc4trl'i-60: I.Q IAttttteinplo�}crteilh .. . 4.[�Eamngencrnicoiitmetormit�l uili[a}ces(fil[atutrorlkut-onto) H1teirlredtho•S&COlitraolors i 2.0 Xatnttsofe- ro rtetorw 1 t 7 �]ItctnofreGn p p` ttt�itcr- listedbtttftenftRcltecls�tee[:�= � Alpnudhave Ito ctnproms T'JAc d6b cotitrletotstilro S Q'DemotEtiait scort-'mg Corin ktt nny enpadgt fL.er'map•knsitrauoe• rj [l'�3id}itiitgtalcSCiott bio�roii crs`c4)itp Jnsf�mnce �•O�l►e_are,a co oratiar snit its tLatmc j Qtticerslrave c�erciset tliefr ttz C1 rleclucn!repair�orttdaimts .�Iantdltanieotrlierdoit�en!l�tioTk r1211torcxeaoptiotlper3l GL 1: filttntGt,tgn utsormktitiont IgyMf.[NO worked!cony,. -C.152, 1tQj611ctAivit9to110 . 12;(:[,Roofreparrs tinuranco rcgaired j;t eEiilAoYces.tRo, orkecs"' j3,[j ptitec f camp.illus-Anco!•ei}nlrcd j { 'Apyf33t.T riestG+feG:d3bmut 111GArlso riillcast(L•csetii.aMoir stwutngtteiirnrit.�s`e.-inrruu�Uonn�ltt}tnl5tutitiat Ei �t{.yin.tttfl \ritnsuUnFitEtusdi-Aiulttndirelh)aMt!•rredeltgnSNrafkredMuth(edafst6tOM .rn43RMA'S11+11itn6hi-Q(f'L tcilt�t3it5k-suit. _ ltbntnxtrt:ttiisf�i�ttitri3tJ�GHtifn:laiiaSnnr.•id�tto�3lsTt.tsLaueFt�tT:.n;nic flSts[itr[.�n2re.f�+nrt3 piartiiuFai`e"i;p-r4tyktrannalcnr 1'rt//1fFr4•F(1I�)�t7ic'P/�rQlls�iOl�(lE(Ibort'Blhc'!S'Ct)pjryrrSAflAlrlttSt(FFlI(Cert/pl'�ltlpiUt•res l3etotnfrflrcpolle}�trtirt'�nGsll��� 11�farrrx/rtor/. - i)1sar►nceConr}snny�Aiui�c 'Y! 8�-�.�ti----✓-- .t'o>~ic�ltorSe[fi►rsrL'te,/i:. . .. _ �jii'tYtk�iiTT.iie•. Job Silo Ac'tilcess •�(U �` �Cr { �G�iiplSt teT2i :. 1l[itscltncoti}:t2f(ke�cotrters`cenr�ens. ioirpDle�y iketn�(rotrpage(siitlturtcglfi�jialteS t�irttrb�t�iEt[B��spri�t�Iartr�nC�: 11'crttiolQSL'�t)Yt t(Ttseli1�315!'Eglilr�(t'[Htder'SECti0lil5/Y OkR(CC3T;.o. t f$2c6n,lead,tothe l'nipo�IfU pfcrprlFni{ (Tpr[:i�dm.ot-& Bliss lip to"SE, O.00 andloi Que earImpriso)nnent,as stets as clivit penalik-&k'iYie form oE'rt STOP=\l'OtLtC O1t0�L�[t iiritla t'triG oful➢IoS2Sat}tha'da}iagarttstttl¢�rol((tos, tJcaertiseillltictoca}tyallliis[atcnzettYina,[re€octiaraledtoll►erUEficeof tttf�estigtilioscs of[Fie I3f/i t`ar koseimEiceco�cr(+ge t�eriGen[ion. � Irlolrerc8j fj+/rx et rfea inall rfpe, ar'lieso erJxrt<Jff(sol(s=lg�ainr(rl7bjr rb tFi tcrtiot Ps.lyxF�(fttkeor�ecl. Sieh iTitr,. 1 � ` 1)AI • 2—" }its �r 7 9 b U F,� 2-� • F�O'u" Pa rro[tvi`�'�Fir lfrPc Rrerr,to lra caut1?fetutfa�C1 ft+orCal)y(eirdeostc):lttr 2.1Ttiritlitt .1?e}tat:tutettt 3•C}fltt'outtCtei'l �i.r cc to4instimo C:1'1t�nrG&ig,i)rsyie tot.. 6:Other- Pit ther Cptifitell�Ci .o{rs PiioliFfh �I • L i Itfias$itcl " 61 ""'1"chapter J52 t ginlipig'tt, "toil foF!]teic�entpl��ees.. I'ui UatYtto-Al"tatut(L.Ott eitWrqptigllefiitectiigs" Kirii perso>kftt{iie6etiticeo€atiotTicit{ader#gyrconfraCtofLue,. isiais of nitpliecl;,$ral or+tiiltett�" Uk610,103<erlsdtslirledigs"Apinillvldoalypaititetst�ipi,nsso�iation�Coj ipi- onprotheileg tellivikaranj►tw6bkoioto ofit]teforagon epg�gecima ot+ttenierprrs,aiecTtiiztitcTtn tileIeg Ir'hprescntatii<eso adeceasecfeiapf6jfe,orate reoen�er•©rttustee=o£wtGuititdttal,IiattnBr�llpt,9Ssdetattfllt;or'OUierIBpalenftt;,,,etpli�oiriagem�Slayees,l`Iotttetie>*tlic otivner ofa dtvellritg hotue Iiavntg nottnaie thaw th=-spattutent"ud' ilio rosiites tfiereitt>j of tate oFcnpautoFtite tllveZliitg I►onse<ofanofher•tvlto emp1o}�spetsons to doanaiittenance,eot�stntction orrepairCvorl on sttcllclittflingItoust r3tpu:th�grounci�orUuilcliitgAJtpt+rfenitnttltereto.�balruot•becigtrseof'sucdt_einployntentb.cl°.entecKebe�aempla}<er." )\SGL chapter 152,-Vit(6)also states tlta,F`•`evoi t+sfafe o�ioeigl IleeatsingngeiteysltrtlF�QFtIiFtolcTtitelss;raueeo 1'etiettTl.o n hctsl?st oa Irertulkta operaiett Gusittessor toeottsfrf+cE Gtillcliugs in file comtrioittYealftt Toi any NTitcattf�vlt�ltas•I�of prtrliut`etl;tccellfiibleevlcleitce oTcoinllliigitce�vith.tkeiistiriiueei aver{tge regtdtecl" AtlditFonalTi; Gl;cli(jgor132,fi25C(?)siates"Neither lne+comniontvealilinorany ofitspoliti6d subdivision shall 0s 4� rintoanycontraetfortttaperfomtafrceof ,tblicwork;uutilaccoiiZabTeevicieitceof�onlplianc�i�rifiifiiFinsurcince retjttiremenis ofthis chapterliave lrectt pres�•ufeci fo tliG co)itracting autltority<;' �1.jiplichltls E3easeftlCottt 1100tkers1;calllpeiisa[io>rflYfthat+it�tinipTctal�yx 3�1�7ieal:i�tgllebotesth taplilE<# yoiiisiluatiolttin • neces�ntj�stt 1<sttb contractor s natue s aticG•ess e� and Ttoltenmtitl�t�s�atalgtti<ittttfteircei#iGcate�s}pf' 1 nzt}raitce:•L;ntttedtinbllifyyCompat�ies(LLC}orUnrted fabifitjlPatiiioiships(LLP)taidinoentptoyecsotltertfisti:t`ne Itiefilbersorparfnets;nronotrequired tocariy Ivorkets'cogtpensationinsurance.IfanLLCorLI,Pctoeslmve- 'mt iloy ecs,sipolicy is required._M edvised'flint this 9kiidavituiay 6e sitlrmittecl to theDepartmento£Industrial forconfuntafioilofinstualtceEovefage: AYsbbest+refosigitntidtligtetices+fficlavit 1'lierfildavitshould berehnitet€tofleecityortownthattltctipp7ioatioufor The peturitorlicenseisbeingrequested,trotIlia Dep antentof Fitcfc�irirl A eeidettts. Shotiid you hitt nny'gnesl[gt+s rcgnrding.ilie fate itr ifyoti are required to ubiabt a ttrorlcers' 00kiike}]otion policy,please cal!fhe D�liattine+hf tjttlienuntber•listed below.=Self-Insured couilim es tiat►Ic!cnfertitcir pelf-insurance license numberolUlLe,Qpropriate.Iine Cikv or T91vit omelals Please by sine tltat.tbe affiaavit is cotilplet�9ucllirinte�.legi61y. 7liebepatfttient Itasltroviciecl a;Macs at tlto boltont .ofllte,aftidavitforyofttofill bifintheeventMe.Off imofFm<estigationsh2stocolttact}�ottr8gat uigihealrplicant. Please be surd to fill in thepennit/1;ce1Isennmberiv]tichtviil.be,used-asa.refereuceti;tulfier.Iitadfiiinn,ignapplicattt titaf'must suinilit utuldple:pormiJiicense appiicatiolisin anysgiveit year,need ontg sulintiC one aFfdavif fndlcafing cnn4nt PET Information(ifnecessary}mid undei"Job Sita Address"the appiicatit:should write I'M[Iocaiions in . . (clW or tqti%Ih)"'Acopy offile:a[fidavitflintiaslieenofficfallystampedortnarlactUy<thecity<o:fot rntaSbeprovidedEoftte ' j aliplie,mtasprooftha€atralid''tfficlavit solilitbforKittireperuiitsoflicenses.Alietyriffidavitmusttiefilled out mctt wAr.111erea lionte otv net orcitizen is ubtainivg a,license oiperniit not related to anybusiitess or.contntercial veriture € (c:e,a dogjicense or pefntit to burn leaves etc)saki person is NOTietluired to completetltis ti ffrdn'. ,Vie dVoe_ofll1w ftptionsa1,0111dJii:etothfal`Yotrinadvattcefbry91irs04o;itdyottlt:ii�i?ity<questionsE p1gasedOnot ltest[aleta-gi4 tt5#tcpli: • . Titc Departtill:nf'sacldr�$s,tclepltolte antY fax nti+tafZer: i The f 0` II1I�2(ItLTBi tl�t tf1£l�I t[S$if2}itlsett 13eliat-linent afbCduAeittl AoeYmits �1'Cce ofIttt<e�ti�at'�o�t� 6001vashillpit Sfreot Boston,I1 &ON 11 Tel.0617M7- P0009C406 of 1-877 IVIASSATS I eihed 5- AM it 611,121-774 8 9 b.b Date. - J HORTp O� MTOWN OF NORTH ANDOVER..•o ,.SO PERMIT FOR PLUMBING �,SSACNUS� p VI This certifies that . . . . l/'v.n14'l. . . . . . .� . . . . . . . . . . . . . . . . . has permission to perform . . . .j21n.� . . 'I��.$�,� . . . . . . .�G!/. . plumbing in the buildings of . . . e" 11 P�: :.►'1.�. at . . <�. . . ,. 1{.�'q kc . . .!��5 -. . . . . , North Andover, Mass. FA.35..c . .Lic. No.. �� � �'.�r • • . . _ PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town SLA D0l!'iri/2 , MA. Date: l Permit# Building Location-7 U dITC1#11VyA03/ Owners Name:��/�/j "ff2 1CLe SS//V/S' Type of Occupancy: Commercial❑ Educational❑ Industrial❑' Institutional❑ Residential New:❑ Alteration:[ Renovation:❑ Replacement: Plans Submitted: Yes❑ No FIXTURES DEDICATED Z SYSTEMS H Z uLn W Y > z } in _ ,n W Z O. W Z C Z Q _z Q Q V7 Z Q d' W to Z to W E.. Q 3 N = Q W y H W QQ y Y K Q WO Q Z OC 02 OC Z Vf u a U. = Q 3 QO Y = 3 Cn 0 � �+ = Z Q � 3 a Y a E W W W Cd o W 3 W J a s v=i vai o o h > > 0 = o a R a a a tr a m Q Q m m o o z be 3 3 a: H In r, M 3 3 3 o a e , LU 0 3 SUB BSMT. BASEMENT A ST FLOOR —OU FLOOR 3 RD FLOOR 4T FLOOR ST FLOOR 6 TH FLOOR 7T FLOOR B TH FLOOR ��/ Check One Only Certificate# Installing Company Name: i7ll��' � Z&,/ p ., ❑Corporation Address,/,/-/1-r(jX �✓� L/V City/Town: State/V/ [3 Partnership Business Tel:6o3 Fax: ❑Firm/Company Name of Licensed Plumber:6,2 - pl 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 of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWN SURANCE WALV i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mia. sachu tts 9pfieral L�s, d that my signature on this permit application waives this requirement. Check One Only Owner Agent ❑ e of Owner or O ees A ent I hereby certify that all of the details and information 1 have submitted(or entered).regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Titre Plumber Ngnitur4 of Licensed Plumber Cityfrown 0]-Master License Number: �9 71eAPPROVED OFFICE USE ONLY) ❑Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents fie 4 Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information . Please Prinf Legibly Name(Business/Organization/Individual): � Address: /1 r—daC dpi V 14- , City/State/Zip:,LS44,�Vl 4W CS 7 5� Phone#: Are you ala employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for mein any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l Jo"Plumbing repairs or additions inyselE[No workers'comp, c. 152,§1(4),and we have no 12.❑Roofrepairs insurance required.]i employees.[No workers' Un Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors acid their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance'coverage verification. I do hereby cern nder the " s a d penalties of peijury that the information provided above is true and correct.' Simature: Date: ��- Phone#: FIf ?9 S� Official use only. Do not write in.this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing 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 of 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 ofa 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 bokes that apply to your situation and,if necessary,supply sub-contractors)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 cant'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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen-nit or license is being requested,not the Department of Industrial Accidents. Should you have any.questions regarding the law or ifyou 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 pen 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 pen-nit 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts DvpartmMt of Industrial.accidents Office of Tnvestiptions 600 Washington Street Boston,MA 02111 Tel.##617-7274900 ext 406 or 1-877—MASSAFE Revised 5-26-OS Fax#617-` 27,7749 www.mass.govldia CbMMO�VWEALTH OF MASSACHUSETTS r: . PLUMBERS AND GASFITTERS LICENSED AS-A-MASTER PLUMBER ISS_UES THE ABOVE LICENSE TO _ry ( GREGOR`/ G PHELAN =a 114 :.F0X RUN LN SA.LEM NH 03071281.,. `9718 05/01/12 '. 812070 i 4 • II r` HP Fax K 1220xi Log for NORTH ANDOVER 9786889542 Jun 14 2006 12:17pm Last Transaction Date Time Twe Identification D r i n Pages Result Jun 14 12:16pm Fax Sent 816175070405 0:31 1 OK v " Date. ..... .... . ........ NORTH TOWN OF NORTH ANDOVER pF „ao ,,�ti0 PERMIT FOR GAS INSTALLATION SACHUSEt ► This certifies that . . . .' .. . . . . . . . . `... . . . . . . . . . .. . . . . . . . . . . . . . has permission for gas installation . .'. . . .!: . . . . . . . . . . .: ' in the buildings of ... . . . . . . . . . . . . ... . . . . . . . at`7�. . . . . .!::. . . . . .`: . . :/. . .'. :. . . ., North Andover, Mass. Fee.'•.. . . '. . . Lic. No.. . . . . . . . ... .�. . .'.�'.�.. . . . . . . . . . .. . . . ;r GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer SL\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 3!X (Print orATyype) V vMass. Date Permit # Building Location . �/D ///%C,VIA& TOs T�� Owner's Name 1,4 134 i A/E 2 ~` Type of Occupancy_ /'��i New Renovation ❑ Replacement Plans Submitted: Yes[] No ❑ .G rn a / Y W N Uj NN V Q N to cc N a p N H F 0 J N W F U m y of z a u acc o r al cccc m to F- W O a c N NN zOU W = _ ~ N O. W W W df j z Q z cc c W cc W h W _ car '. N a C yz a m z 0 z o Wzan z U1 > JVaYay Z O :3 O 1 1 ©uT'5i0E I BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STIR FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate Address 55 MARSTON STREET X7 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone .68,7--1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes R( No O If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance y ' dY policy �( Other type of indemnity❑ Bow ❑ 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: Signature of Owner or Owner's Agent Owner❑ Agent ❑ hereby certify that all of the details and information I have submitted(or entered)inabo plication are true and accur gte to the best of my knowledge and that all plumbing work and Installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. T of License: Title Plumber Signature of censed Plumber or Gas Gasfitter City/Town Master License Number 8697 Journeyman APPROVED O FIC -S ONLY BELOW FOR OFFICE USE'ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. APPLICATION FOR PERMIT TO;DO GASFITTING c ' NAME 11 TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE GAS INSPECTOR � _ r Location C rUs No. Date 3 t NORr►,, TOWN OF NORTH ANDOVER j a Certificate of Occupancy $ } ; Building/Frame Permit Fee $ < Foundation Permit Fee $ sACMUs dL .O#er-Permit Fee $pn � Sewer Connection Fee $ Water Connection Fee $ TOTAL $ h =� � 5 Building Inspector _97.50 PAID Div. Public Works P,KRA lT NO. £--o APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. V PAGE 1 MAP 4qO. 6' LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE I SUB DIV. LOT NO. 41 I /Loc , 13.7 LOCATION V O 1//�„/111vK , bsF /,)N PURPOSE OF BUILDING ^f�//�f1A s�G f}�"7 4 OWNER'S NAME / n`�//O7iw/►yCey�'CJ /TAUT!/ — NO. OF STORIES 'SIZZEb` •2,0x'C/"o 1 OWNER'S ADDRESS 7 o /'S//7J/rC � /7/`0+�.� BASEMENT OR SLAB �� -1A1 1 y lf�W�� l 1' G4)IV/rE ARCHITECT'S NAME 7...�--� T fN SIZE OF FLOOR TIMBERS IST 2ND 3RD 3RD BUILDER'S NAME 222ND IfQN1 j J i C SPAN --- DISTANCE TO NEAREST BUILDING /Gr /F DIMENSIONS OF SILLS --- DISTANCE FROM STREET 7,5/,1. " POSTS DISTANCE FROM LOT LINES-SIDES /lQ' REAR .. GIRDERS -jwr AREA OF LOT L/? /.i1 FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW (`�Pf G_fJ SIZE OF FOOTING X IS BUILDING ADDITION J/J MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND -- WILL 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 W INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST coo, PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS'MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR le7gl DATE FILED (p BUILDING INSPKCTO* GNAT OF OWNER OR A ZED AGENT FEE v OWNER TEL.# PERMIT GRANTED CONTR.TEL.# 19 CONTR.LIC.# H.I.C.# R - I ic a r BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY I STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I 8 INTERIOR FINISH CONCRETE B 1 2 13 CONCRETE BL'K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER _ DRY VJAII UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'TAREA _ 1/1 1/1 1/1 FIN. ATTIC AREA _ N_O B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 77-7 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARD1u'D _ ASBESTOS SIDING _ COMMCN __ C VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ r. STUCCO ON FRAME BRICK N MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE ` FORCED HOT AIR FURN. TIMBER BMS. G COLS. STEAM STEEL BMS. & COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G i UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd 11 NO HEATING I N O R T I.1 F Town of 0 over Y tool � 10 dower, Mass., 19 COCHICHEWICK A0RATE1) S ` BOARD OF HEALTH PERMIT T AD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT..................................... /9. /�/ �.............................................................. Foundation has permission to erect......... Ca d. .......... buildings on .............!�&........, / ! G.... d. .. ' Rough to be occupied as.......................................1:1)7_.O.. y©............� 7� ......... d. /............................ chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST TS ELECTRICAL INSPECTOR Rough ....... ......................................... Service BUI DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough P Y P Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. _�`� Smoke Det. PERJIIT NO. D I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. MAP h40. LOT NO. 2 RECORD OF (DATE BOOK 'PJ 6'S I � OWNERSHIP I ZONE SUB DIV. LOT NO.� I LOCATION O 41J/�/� PURPOSE OF BUILDING (.✓/ 1.�� �O OWNER'S NAME 7 ry T� UY1� NO. OF STORIES SIZE �O x CICO I OWNER'S ADDRESS/ �/� �� BASEMENT OR SLAB V O /�i R dl r POSTs:V: ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME /! ' CorV,3- J w(f SPAN --- DISTANCE TO NEAREST BUILDING /J DIMENSIONS OF SILLS - --_ DISTANCE FROM STREET 1+ POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT LJ7 L/O FRONTAGE HEIGHT OF FOUNDATION THICKNESS . IS BUILDING NEW/ _7 Jr� SIZE OF FOOTING x YE=S 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 3 PROPERTY INFORMATIOP INSTRUCTIONS LAND COST 41 SEE BOTH SIDES EST. BLDG. COST ' co EST. BLDG. COST PER SQ. FT. PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS I - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING 11 GNAT OF OWNER OR A ZED AGENT FEE C� OWNERTELJ PERMIT GRANTED CONTR.TEL.A 7�-R 3_--;eS r3 19 CONTR.LIC.# H.LC.lJ ago Y APR - i FORM U - VERIFICATION FORM I� INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************.Applicant fills out this section***************** APPLICANT: , Phone LOCATION: Assessor's Map Number Parcel Z 7 Subdivision Lot(s) Street 7 / /���' V g St. Number ************************Official Use Only************************ RECO DATIONS O WN AGENTS: Date Approved Cons rvation dministrator Date Rejected Co ents Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date The Commonwealth of Massachusetts „a Department of Industrial Accidents ly 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit 1 scant Information: Please PRINT leiibiv l name: location: _ city phone# ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one working in any capacity. AI am an emplover providing workers'compensation for my emolovees working on this iob. company name G v✓V�T/� address: —/' 7Y �As6&)A� city 1,Z 2—70-W />4/4 phone# y62- 332:5 insurance co %�J ���V n j7/ �4poiicv# 72 ❑ I am a sole pproprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers'compensation policies: company name address: city phone# insurance co policy# company name address: city phone# insurance co policy# ttac a rtio I .Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up tol$1,500,00, and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me" I" understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. } 1996 Signature Date Print name Phone# otlicial use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Buildin:Department ❑Licensi ❑ check if immediate response is required ❑Selectm ❑Health [contact person: phone#: ❑Other 1 _ 1 V. IDENTIFICATION (Type or Print Clearly) OWNER: Name Phone Address LESSEE: Name Phone Address r CONTRACTOR: Name Phone Supervisor's Home Improvement Address License#: License#: ARCHITECT: Name Phone Address ENGINEER: Name Phone Address VL READ BEFORE SIGNING The undersigned hereby certifies that he/she has read and examined this application and that the proposed work, subject to provisions of the Massachusetts State Building Code and other applicable laws and ordinances, is accurately represented in the statements made in this application and that the work shall be carried out in accordance with the foregoing statements and in compliance with the provisions of law and ordinances in effect on the date of this application. Please type or print clearly: Name of Applicant Company Name Signature of Applicant Address If application is made by other than the owner,complete the following: I hereby certify that the proposed work is authorized by the owner of record and I have been authorized by the owner to make this application as his authorized agent. Signature of Agent Signature of Owner DO NOT WRITE BELOW THIS LINE Application received by Date FEE Sq.Ft. Rate Street Cut bond posted N/A State Building Code Approval BSMT(U) _x_= Zoning Approval BSMT(F) _x-= T.L.S. x = GAR. x = OTHER x = BUILDING PERMIT APPROVED AND SUB-TOTAL ISSUED BY: PLANS x $3.00 = Building Commissioner TOTAL = ''•4 yc4t �y j's vccr.b+c a*�Gcso on-ae.-sTkT OacAL 001 1.O•C.fAGY WLY 1e• OGtOW TOP Of EO.40 04•••1 O0V*A TUM -•. - .. TMQOUG"OUT TMs 10011. cov0 w0<•P '10'MIN• wTO SWOZ fOfA _ Ofuc lfvil� -- 104 f&CGSS OP 7'-0' OIPTN. All 11 I �4 t 1'•G. wt. � -7- so QAa CONSTRUCTION, INC- 4 t t s,� r w� �•A-sss�r•a• - •�',yT.wovsuw,rl'ac:�•o'lc. 1•VCa)•.1 TOP Or Fl CQQ i1 8-0• ;•�STGLL H&25 FtA)m STV*L VAX'U- DEEP EI•ID-9-`JMAv-DEPTH •---14u lww EI.+o _ • _• . G17M71NI IOU�i C►A•1l DEPTI+ LOMC;ITUDIMAL SKTION TL12U CEl�1T:Q a ♦' o' ' �" OEC1C IEVGt_1 ^Z• - bYYI-TTS' L5'�.'GL 1 - -- B^u � -. .- .._.�. _ �:i a�:s zil-=1✓' _ I — e• ccet►�c nu. vc¢T. vmr IL (FW5T LA IN FQEFZING C1MAao 9-o viceTICa.� � I I l.tlovvGO 6 � pccop w.xluuML-- - �- Iua.V-0 •-r Y I I (iF{QGG.X TA 6'IN So a/•4 .' �� $i• Fas�zi Oz<cxt�pN�rvG . ng k4A,l• _ I I SCCT O AT 51 d - ►uiu¢eu_ FWrS"C@MGNT TIb ►02 L"DSTutwo COAojc-NT -SOIL -- _ _ (w•rc¢ oamP• • GIN SuG� Sc.&ION AT MAIN WAIN 1•vanwm.AO,n,sMAG14T OF of . _ w"rTG.) I ►npOpSTTanG //CQl • ' •� QGUEF %&LVG•� .. rOg 1 ac•Nr DECK emM CWM MARS TO ACCON004TE —9��T� '? X-V41(C AMSAIIGNMN•1T '! �E' ,- - - TO p POWM `FQKi1NG Cil s)lAhm VG 4'• • CC+nIDu1T '' • � '-; :• j4� • '; _ ' ' •• 111 - ; STiGI b.2, g! �• ♦ i 47! r AQO1W0 IK.NT NICN4. � 1 - fuaOQ C�11 D - 10 PJM? u �- �,��tA-SNOTp, �T>cEL 64cs - �! �1�•''••-��y �QAI1No MOrNOQA1N I�t 1 •Ib'---� MnraowuH curs •`fir II . G t, UNn-QWATrfV LIGHT DETAIL `,�I IMMEQ DETAIL ;Y +.,• .+� 1.. le'.re xW oa vc1- -%ULAA E UIPMENT LIST w.�• '`�.�) i CUN 8 ♦B'pater"7 TO Au- a •- c••11CK 11. : - P� J ; wcr SSS-crll wrt•1 }' man lab � QetZD w M .�'r.Cj�stisTf R G BWZMQVIPI— grx rirrrJ�7 ..o.«. •,. �'� 6u .rr• �J� wn 'r. • -4.rP.r1M�.��•ryr.l lri.•r..-.M MNOGNTICNPL P S- MAINOQAIN SUMP: D All. .. r•w...r t.wP�.•.�++ NO2AML 1DCDG SdIS w 4'510 �le-van�nnonuseal!/�o��/�.craaacluraP,tla Restricted iai 00 27727 DIPARTMBIT Of PUBLIC SURTY COBSgRUC t SUPBRvISOR LICBISB 00 - Ione wke = Igiresc Birthdate lA -Masonry only 1,';09/29/1991 99/2911931 10 - 1 E 2 Yadly Hoees 1,-!' ete = 00 failure to possess a current edition of the � ; Massachusetts State Building Code '4 Oro 57—_WJR S ZAGORSHI JR is cause for revocation of this license. -A 2VIBUBURY ST PBABODYF MA 01960 APS`- I M b �, "1,-eur-. .�•�'�:`. i c.� - ^-.i".,:..-`h'` wrea� - t: :y' -,n;�'+.'^.w .-►, T ,.;;:'�c.. .•vi. � I.'�4. F i N_ -. .. ."eair .� �'r _� .y3•i F F i{ I CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE: 1"=50' DATE: 2/15/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. --- 4 i 00 app � s i 1 f 16' r LOT 6 \ s19 43560 S.F. -y 1 0- ? 2� r � f V s LOT 7 � I CERTIFY THAT }j OFFSETS SHOWN ARE FOR THE USE THE OFFSETS 8 OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE 3972 WITH THE ZONING DETERMINATION OF ZONING FCl�tEK�° BY LAWS OF NORTH ANDOVER CONFORMITY OR NON—CONFORMITY WHEN BUILT WHEN CONSTRUCTED. Location 40 No. Date t►ORTh TOWN OF NORTH ANDOVER Certificate of Occupancy $ OW Building/Frame Permit Fee $ Z. Foundation Permit Fee $ s+CHus -- Other Permit Fee $ Sewer Connection Fee $ BA Water Connection Fee $ M — TOTAL $ Z I S Building Inspector ector�3It)31 21159.00 RAID 8" Div. Public Works Lot Location 4o �ctoJY6s No. Date p RTp TOWN OF NORTH ANDOVER p Certificate of Occupancy $ 4 ; Building/Frame Permit Fee $ �'"�°'•"°'�tt' cMFoundation Permit Fee $ s� usE Other Permit Fee $ ' Sewer Connection Fee $ Water Con ection Fee '" $ TOTAL $ Building Inspector 7897 �� Div. Public Works Location No. o-40 DateOf 00*TTOWN OF NORTH ANDOVER Certificate of Occupancy $ c Building/Frame Permit Fee $ Foundation Permit Fee $ / Other Permit Fee $ 1 Se%'ver&nnection Fee $ Water Connection Fee $ h577,� ' TOTAL $ Z�7� S21 J 1 _Ruildi Ins for * 1 n 4rJ .f3 Div u Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP KJO. �t^j I LOT NO. C v/ 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE — 70NE SUB DIV. LOT NO. G F— I f LOCATION PURPOSE OF BUILDING Ioos t.- ,rte f 40 _ S,A,.le Fig, 3 (1dA g6&6PIe I NEIt'S NAME / NO. OF STORIES SIZE PWNER'S ADDREig BASEMENT OR SLAB ARCHITECT'S NAME -��I v�•� SIZE OF FLOOR TIMBERS 1ST A �D 2ND �x 3RD BUILDER'S NAME �'VJ <"��I. hjA� SPAN --- DISTANCE TO NEAREST BUILDING Gv DIMENSIONS OF SILLS DISTANCE FROM STREET , / '� POSTS DISTANCE FROM LOT LINES-SIDES •7o/ REAR v/ " GIRDERS AREA OF LOT / X 17 i FRONTAGE / l HEIGHT OF FOUNDATION C�y� `/T THICKNESS Jv yIS BUILDING NEW ! i/C f ` -- SIZE OF FOOTING O % IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE C IS BUILDING CONNECTED TO TOWN WATER z;-- BOARD OF APPEALS ACTION, IF ANY / IS BUILDING CONNECTED TO TOWN SEWER V C S IS BUILDING CONNECTED TO NATURAL GAS LINE Y e S. INSTRUCTIONS 3 PROPERTY INFORMATION SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY LAND COST REGULATED BY PARA. 114.8-S. B.C. EST. BLDG. COST . 3' � 1 4C !S PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. _LTJ �i i EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 DATE •7( -L, FEE PAID tom' SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING DATE 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FI BUILDING INSPECTOR SIG A UR O O ER OR AUTHORIZED AGENT V• F E E 2PERMIT FOR FRAMUBUILDING OWNER TEL.u 9 7 PERMIT GRANTED c3c� C/O CONTR.TEL.# �' 7 3► ,9 qs ATE: S�FEE PAID• �' CONTR.LIC.# 2 y H.I.C.N =12 6 LEE W . lot, ( l br-A �- rtz i3 BUILDING RECORD 1 OCCUPANCY 12 , SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM' MULTI. FAMILY OFFICES _- LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION _I 8 INTERIOR FINISH CONCRETE ✓_ B 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDWD PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT C - AREA FULL FIN. B M T AREA _ '/ 1/2 '/. FIN. ATTIC AREA NO B M FIRE PLACES HEAD ROOM _ MODERN KITCHEN 4 WALLS I 9 FLOORS % CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE —— �— WOOD SHINGLES EARTH ASPHALT SIDING HARD"J'D _ \ ASBESTOS SIDING COMMON VERT. SIDING ASPH. TILE / STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR BRICK ON FRAME CONC. OR CINDER BLK. 1 `� STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR IV ! _ ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP ✓ BATH Q FIX.) GAMBQELMANSARD TOILET RM. (2 FIX.) L FLAT I SHED WATER CLOSET ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES r' / TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST / PIPELESS FURNACE ' FORCED HOT AIR FURN. TIMBER BMS. &COLS. / STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR - WOOD RAFTERS ./ AIR CONDITIONING RADIANT H-T'G UNIT HEATERS 7 NO. OF ROOMS GAS IL O �. .. .-«�.iwa• ..�... r 6 i ll.. s6f ibt�i , B'M'T 2nd ELECTRIC 1st 13rd I NO HEATING 0 o �� or over 0 ,< No. .040 _ j .11North/ Ayy ndover, Mass.,Zarin .4 3 19�,S cnc+uc ne wu.n DR.11ED T ' t BOARD OF HEALTH 0 Food/Kitchen Septic System PERMIT T n A BUILDING INSPECTOR THIS CERTIFIES THAT.AtD.Nt .....4�,ID. .s �lA1C-T` ..... .7be. n.M ...... �................... Foundation 1�a .. has permission to erect. ?I:?......�tA>�fll�., buildings on ..�.�?....'�t'k-.Ef:!!�?f►.........�....P�............C19*..46) Rough to be occupied Ai.�rnk1. .. ��.�... . .c6 ....'54 ?.......(*M2 6E.......................................... Chimney provided that the person accepting this pOrmit shall in ev .... re ect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA 114.8-S. B.C. Rough PE[ N/tIT r,, P.��635 IN 6 [e✓I.�OI QkTE '; I FEE PAID tea Final c`a ELECTRICAL INSPECTOR UNLESS CO? \] -Z-1�0 J jl :� 6 �1 \�� . Rough .... .............................. .. . .. .. .. .. ... .......... Service BUILDING IN TOR Final"' Q\�� Occlspancy Pbwilt Regtti7(,d to Occupy Bitilcliti PEZ o& Display in a Conspicuous Place on the Premises — Do Not Remove V01Fi No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. oA� Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: '411a>drt7't &o,,.s-) a- OLL& e*?.? Phone 9 7,S- �3 LOCATION: Assessor's Map Number Parcel / Subdivision - /,,, a d S Lot(s) Street St. Number ************************Official Use Only************************ RECOMUMENDATATON OF TO AGENTS: Date Approved Conservation A linistrator Date Rejected Comments �/ 5k )1� &,_k "�� Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected - - Date Approved I fA�_ Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connectionsT(t-c� ( - 13 -95 - driveway permit I .,.J Le) - 1 3 -95 Fire Department Received by Building Inspector Date JACK 2 1; ",tet .A r N S 41°22'47••E 209.64' S 47038"E -phO 1 Op' 6 164.58 4 06 .A rn 0 0 O Lor 6 .3 43 43,560 S.F � �i (� Ip. 409' C.B qa OY Co jun SEWER EASEMENT 190.00' R /p . 72.42 35N ()Ol 33000 ... ` . 150.00' °00 � 2 _43'560 S-F Npo N� (' 100% C.Q,q 2 - —� cr . r • � f ! fi a CERTIFIED PLOT PLAN MAR - 2 LOCATED IN NORTH ANDOVER, MASS. SCALE: 1"=50' DATE: 2/15/95 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. pp �O ��p Q \ �x u o 'sQ LOT 6 s8 0 43560 S.F. �ti x\/. 2�9 52 s�. LOT 7 O.9 O I CERTIFY THAT FF T Of O SE S SHOWN ARE FOR THE USE �tN THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING cJ�, • 13972 H BY LAWS OF CONFORMITY OR NON-CONFORMITY s��fC/STERE0 NORTH ANDOVER SAI LAND S WHEN BUILT WHEN CONSTRUCTED. / 2, t '15 CAO KAREN H.P. NELSON Town of 120 Main Street, 01845 °in"`°' .M' NORTH ANDOVER csos� 682-W3BUILDING �.`� ..'3'.�' ' CONSERVATION DMSIONOF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT ' CHIMNEY APPLICATION AND PERMIT DATE - / PERMIT # V' LOCATION / G� U"O r OWNER'S NAME r BUILDER'S NAME lad � •�� f/1 /�.YL�J MASON'S NAME �u 7` 41 MASON'S ADDRESS �a dkyIV 1/1 MASON' S TELEPHONE d 3- Il MATERIAL OF CHIMNEY INTERIOR CHIMNEY r��� EXTERIOR CHIMNEY NUMBER AND SIZE OF FLUES d�Y /9 THICKNESS OF HEARTH /0 Will chimney or fireplace conform to requirements of the code and have rules and regulations been received: r/ DATE G� �� CON # f ; SIGNATURE OF MASON TR. LIC./ EST. CONSTRUCTION COST/CONTRA T PRICE G �� ,i /• - - - - FEE aft' Location J L� pjw No. oDate S� ofsNO p7:,ti TOWN OF NORTH ANDOVER Certificate of Occupancy $ 49 Building/Frame Permit Fee $ REQUIRED j �N�S c� lt zFound�ion Permit Fee $ �10 ✓U i ermit Fee $ LAVED ON THE PREMISES Sewer Connection Fee $ Water Connection Fee $ 19 TOTAL $ { { _�t Building Inspector WA `� C 2-17 Div. Public Works ' NORT�� ,j `� Town of 0 over No. 040 -- port " dover, Mass.,^' ,3 19 ,5 T O -wN COC HIC Ht WICK 7 E BOARD OF HEALTH PERMIT T Food/Kitchen Sept'. System A `� AV ,_ BUILDING INSPECTOR THIS CERTIFIES THAT.!�IT��C3�.1'.Q.... .� �r -T`�..... �r �..•.....(14P.•••••••••••••••••• =Foundation TD I has permission to erect.t�Q......f�Ct/AiY1lc.. buildings on ..:�.�?....'�'�4•N:.u....4..........�.�`.....�............�1.,c�".!�� � to be occupied as%1Y!(1�1. cl; l.4... W. . , f .... �4.R.�4.... ........................................... 9 throvided that the person accepting this pdrmit shall in ev respect conform to the terms of the application on file in Fina 2 L'zI is office, and to he provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA 114.8-5. B.C. �,(�� , S? PERMIT EXPIRES IN 6 MO I 1 FEE PAID - ELECTR C IN§P UNLESS CON$`I'RUC T '0 ( ou jjQQ(( r G Y��1 � { •x t, .. ' �� . PERMIT FOR FRAME/BUILDING •' ............................... BUILDING IN TOR .;' '► ' e DATE: AFE EA46141annit Required to Occupy Building GAS INSPECTOR j . -_ Display in a Conspicuous Place on the Premises — Do Not Remove I z r 1 No Lathing or Dry Wall To Be Done ` Until Inspected and Approved by the Building Inspector. FIRED PARTMENT Burner 20\q5 PLANNING FINAL CONSERVATION Y FINAL Street No.0'. , J.1 i y-v f ;t!e y i SEWER/WATER i,r FINAL DRIVEWAY ENTRY PERMIT71 Smoke Det.r}.Jc. i)-� l . CERTIFICATE OF USE & OCCU PAN CY. ,e� 'Town of North Andover ��tt T i I k ' A Building Permit} u °l5-orb mber Date� N 71)i± I.< ,�, - � ° • , + - ;' t :,.. ; , °f 1 i 3 itr �.� � ! .� J sr J .t�5 4 it 're ' �1 y..3 - �� 1' ;' � a r.^�!• f' } �.�'• 5 � � � ,� �. 1�i II4 �.. r ,< s 9'ir' s ,�, A A . . f S � a: � + � + 'THIS CERTIFIES THAT i 1 y,{ l ( p•�' +'. d :rt k, e - {�� 1 `. i� a {•.. y }% ! !THE.BUILDING�IOCATED ON �J� Qas`C"' >,,� ,, f ':1 .') ) jl l._ {.:' b. t f�''•� (1,i!p ' f u `}, i r MAV BE OCCUPIED"SAS Q , s Wim'��� -��IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. NORTH t #� `: CERTIFICATE ISSUED TO �'!� _ •�, f``y = €, , t '� a s ti ° ,, )c �: • d • p� ��} t�s,. r r t# t .v u{ ,ls�rx �s y, :r ADDRES W� �I" t bF .i a, •y �.� �, n' � • : +� Y� i,. a �.- � � � emb t ! 1 is'+CHus �� {i'�5 t Building 1nspeCl01' � 11!j� •i, 'S, i ! f �,l r Date......... .... (.2 .,� 2904 pORTiy TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,,�o SSACMUS This certifies that ...... ...... C /rc r C has permission to perform .... �,. ........P.06 �.............................. r wiring in the building of..... 7L................................................ C at...4CG1 .....ed.:................. .North Andover,Mass. Fee...� .d...... Lic.No.k .&3.............................................................. ELECTRICAL INSPECTOR 04/11/% 11:15 �c (� WHITE:Applicant CANARY:Mng 6WP PINK:Treasurer GOLD: File Office Use Only q q�i LIITItI UnjUe# of .49a99ar4U0Eft9 Permit No. o( I MepartmEnt of Public =%afEtg Occupancy& Fee Checked_� e ,4 BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 (leave blank) \ APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (X* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described elow. Location (Street & Number) Owner or Tenant Owner's Address Q Is this permit in conjuncts with a//building permit: Yes F No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service ..20O Amps 42Q/ a 9-d Volts Overhead ❑ Undgrnd No. of Meters New Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work �� ✓� ��orfym PS ��� Total No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA Above'7 In- No. of Lighting Fixtures / I Swimming Pool grnd L! grnd. ❑ Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners I Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Air Cond. No. of Ranges I tons Initiating Devices No.of Heat Total Total No. of Disposals Pumps Tons KW No. of Sounding Devices iNo. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices I Municipal No. ❑Other No. of Dryers Heating Devices KW Local ❑ Connection No. of No. of Low Voltage No. of Water Heaters KW I Signs Ballasts Wiring _77�jNo. Hydro Massage Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES = NO = I have submitted valid proof of same to the Office. YES _ NO _ If you have checked YES, please indicate the type of coverage by checking the apppro�iate box. INSURANCE jZ BOND OTHER (P/le)ase �ecify) (Expiration Date) Estimated Value of Electrical ork S v Work to Start Inspection Date Requested: Rough Final / Signed under the ��Ities o ?D rjury: � /% LIC. NO. �✓��� FIRM NAME �C `o Cl / Signature LIC. NO�c �3 Licensee Bus. Tel. No. Address AIL Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent (Please check one) _347 S x-6 Telephone No. PERMIT FEE S (Signature of Owner or Agent) x-6565 Location No. n ' Date S 3 o,,Nco7: ,h TOWN OF NORTH ANDOVER •• oma p Certificate of Occupancy $ . i ; , Building/Frame Permit Fee $ 1. ^°'Et }ry F�ojund tion Permit Fee $ vCMUs ( l r��:�IIV 1 -- ttt111 C #cr ermit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 25 � r� _ Building Inspector J -� �c� 7 Div. Public Works KAREN H.P. NELSON Town of 120 Main Street, 01845 °""``°' NORTH ANDOVER (508) 682-6483 BUILDING �.'�• .t ' CONSERVATION '"" . DMSIONOF HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT ' CHIMNEY APPLICATION AND PERMIT DATE - / PERMIT # LOCATION OWNER'S NAME BUILDER'S NAME lad � •�� /f1 //.YZ�J - MASON' S NAME �u /��'G`t //✓� MASON' S ADDRESS MASON' S TELEPHONE !. '� 3 MATERIAL OF CHIMNEY � � l INTERIOR CHIMNEY ��C�� EXTERIOR CHIMNEY NUMBER AND SIZE OF FLUES d�Y /oZ THICKNESS OF HEARTH /0 Will chimney or fireplace conform to requirements of the code and have rules and regulations been received: DATE r AW SIGNATURE OF MASON CONTR. LIC. EST. CONSTRUCTION COST/CONTTT PRICE G �� 7 PERMIT GRANTED U[ FEE ROBERT NICETTA, BUILDING INSPECTOR INSPECTED REMARKS SOLID BRICK REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES 2347 Date..��.. NORTp TOWN OF NORTH ANDOVER 1 a? '� ° PERMIT FOR GAS INSTALLATION i • A • i i SACHUSES O J� p This certifies that . . . . . . . . . . . . . has permission for s inst ll gaation . . . . . . in the buildi s of . . . . y. . . . . . . . . . . at U��(�. !lP . . , North Andover, Masf v Fee. .— . Lic. No. Y.7 . . . . . . . . . . . . . . . . . . . . . 243 b GASINSPECTOR WHITE:Applicant -UANARY: B (ding Dept. PINK:Treasurer GOLD: File IS UNIFORM APPL1CATtON FON PERMIT TO DO C3ASFITTINQ (Print or Type) — -- NORTH ANDOVER , Maas, Data f t � g� Building �j [� Ach IN � J Location d ��%/ �/{�G ��/ Permit #Owne �G 7 Name New ❑ Renovation t7 ReplammIn>t ❑ lana Submitted:. yes p t4o ❑ I „ X t ai W W a O '� 0 t7 . ._. y W O O p h S ` O ►per» t 14 31, as ; Ipil O O , = h d h Z30 = i .n F' yei! i O +y 'jto 0 .p 26 sue_esMT. ° •ASIRM INT 118'r FLOOR ' !ND FLtiOR I SROFLOOR ITH FLOOR 4TH FLOOR •TH FLOOR ! 7THFLOOR t STI f FLOOR installing Company Name �j til/ �/ Check one: cr lffic'ale Address Q3 t>yrp. d Pwtnerahtp Business Telephone — ❑ Firm/Ca. Name of Licensed Plumber or G&94* U INSURANCE COVERAGE: I have n current liability Insurance policy or Ita substantial equivalent. Check If you have ducked yes, pleas ndicatst the '�' No�3 type coverage by 1~it��•*pp % box. A liability Insurance policy Other type of Wermily ❑ Sond -❑ OW"t" INSURANCE WAIVER: i am aware that the licensee doe Chapter 142 of the Mass. General Laws, and that my signature on,thisn9 htlt�e the insurance coverage required-by Permit appitcalion waives This requirement. Check e":nalure o pwner or Owners Agent Owner C7 Agent-£1 knaMTe�dgo and that elf that All of the Plumbing work andils and iInsntaltlon ailatlo1nhapve�o��under(or theh ler90 Pertinent provisions of the Massachusetts Stale Qatl G and C� it��g,� mon are"true andIn coaccurate compliance iha best of my e permit Issued for his appi llo II be M compliance with all � apter 1�2 orf.the r(a T of License: G Title PI ber aslitter na ure o nse u�m+�of or as er Ctty/Town Maver License Number 7 D Joumeyman 'V'f'"OWD(OFFICE USE ONLY)