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HomeMy WebLinkAboutMiscellaneous - 40 INGLEWOOD STREET 4/30/2018� �� ^� tl' I V Y J w. Date — ..1................................ ' t NOR7M'1 TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING - ,SSACHUSEt This certifies that ..... .. .�,�..........................................�............... is has permission to perform . ...............� v r' . .f....................... . . .. . .... . wiring in the building of A. ...."..4 f .t.�...�:.`..1.................... ..41e -r f/i- .o...:........... S 1Vorth Andover ass. _. r ". Fee.....?.'......... Lic.No. w iNSPECT611 (Check # ` 10603 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,.§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to.the lergon,firm or corporation stated on the permit application.-Sucl- entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of-ongoing construction activity,and may be-deemed-by the-Inspector-of_Wires abandoned-and-invalidaf 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 Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension 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 beginning on August 15,2008 and extending"through August 15,2012. l ,�l Rule 8—Permit/Date Closed: /G / Note:Reapply for new pert '' 0 Permit Extension Act—Permit/Date Closed: i //�� aa / Official Use Only C,oinnwnweal�o�c7�ae�achu�e�� Y a Ue artment o ,}ire ru Seecee Permit No. P 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 Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFO TION) Date: 3 J City or Town of: I\�(1�(`�\ Y b\(PC 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) y o �3lk.wUOd Owner or Tenant Telephone No: p Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / 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: Install residential security system i Completion o the followin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices j No.of Waste Disposers Heat Pump Number ITons IKW No.of Self-Contained Totals:I Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Conne ❑ �� ction No.of Dryers Heating Appliances Kms, Security ystems: No.of Devices or Equivalent No.of WHeaters KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecom unications iring: 0 No.of Devices or E uivalent OTHER: q 0 D Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Elec ' al 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 substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Nightwatch Protection, Inc. n LIC.NO.• 7024C Licensee: Paul DelSignorSignature IC.NO.: 7024C (If applicable,enter "exempt"in the license number line.) us.Tel.No.• 888-722-9282 Address: 22 Briarwood Drive, Westford, MA 01886 Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. .SSC00000969 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ 55-,�� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mass. 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): / wa��(�G' \ T�� q Address: �50 City/State/Zip: SaLQm vo 36'T� Phone#: 7 a a- a 6 a Are you an employer?Check the appropriate box: Type of project(required): LV ' I am an employer with i1 4. ❑ 1 am a general contractor and 1 6. ❑New construction / / employees(full and/or part time).* have hired the sub-contractors 7. ❑Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp. insurance.t required] 5.Li We are a corporation and its 10. ❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑Plumbing repairs or additions myself [No workers' comp. right of exemption perm MGL insurance required]t c. 152,§ 1(4),and we have no 12. ❑Roof repairs l employees. [no workers' 13. Other 5 ecu ,c� S�S comp.insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attach 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 thepolicy and job site information. (� �,{� Insurance Company Name: I�ay.40 rA �' y 1 2). CG . o Y LSL ti lots Policy#or Self-ins.Lic.#: �j� L J w lQ Expiration Date: t o� / o h p2 Job Site Address: T City/State/Zip: Wl dvt�, U . 0 (5 1-) le 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 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 $250.00 a.day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certi&under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Print Name: ki fox Phone#: Official use only Do not write in this area to be completed by city or town official City or Town: Permit/license#: Issuing Authority(circle one): 1.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#: Fold,Then Detach Along All Perforations ^ lUEALTH OF MASS BOARD .- - LECTRICIANS FA _ UT E , EM TYPE C �` O = .. D °fpofQssfona 0 85.6028 Fold,Then Detach Along All Perforations AUTHORIZED Nightwatch DSR Protection, Inc. 50A Northwestern Dr.,Suite 9 Salem,NH 03079 Kevin Gilli an 15 Holly St.,Suite 208 9 Scarborough,ME 04074 President toll free(888)722-9282 x121 kg®nightwatchprotection:com www.nightwatchprotection.com D �a�tYment,of P= bticafet r7R �4shb�rr� nlace tRm'11 Bcst4� M a 108 161,8, Number SS CO X00969 Exp'ices �D�30I20 2, r Rest�tcted To, 00 PAUL bI,3tG�TOR PO BOX`24i' iiV-B ID.C'rEWATER, MA 02379. ,' r i x I" ` L��Oj jn»o'. 199D f dd sem* Ke top for receipt and;changa c a rasa notification DPS-EA1• G 40M-08/08DI361PP 7RM&AID8212008 : ✓ft P..T(�O�ll/IISQ�tIG :O��/Z�QtGiOPldBud,� Qom, DEPAi'tTMENT OF PUBLIC,SAFETY :'• . S` LlcenSe ' ,, r � Number�`,�SSyCO 0.09969 - F.XpjreS �9 '10]2 Tr no: 159.0 '�EMU S n� i �L ALARMS PAUL' DOLS{GNO t *= J 1 BOx 4)V:IiM W:;f3RIDGlsfIS1AT�R�-�4`�02S'/�9 e��- pIG SAFE CALL>CENTER ,(88B)344 7,233 Commissioner Jan 83 2812 10:27:86 EST FROM: FZM/39440007646 MSG# 17670020-007-1 PAGE OOZ OF OOZ SUMMARY OF INSURANC$ TxL HNxT.r ORD FOR: NIGHTWATCH PROTECTION INC Prepared: 01-03-2012 50 NORTKWZMTERN DR # A UNIT 9 SALEM NH 03079 Phone: FAX; BY: HOME OFFICE AUTOMATIC DATA PROCESSING INS AGCY 250717 PO BOX 33015 SAN ANTONIO TB 78765 Phone: (877)187-1316 FAX: (888)443-6112 ACCOUNT POLICY RECAP Policy Number Eff Date EXp Date Premium . Workers' Ccmpensation 76 WEG JW2466 12102011 12102012 $16,343.00 Hartford Ind Co of the Midwest POLICY DETAIL Policy . Workers' Compenestion Worker's Compensation Coverages Employer's Liability Limits Limit Disease - Policy Limit $500,000 Disease - Each Employee $100,000 Each Accident $100,000 Individual Includediftcluded This Summary and its attachments provides a high level overview of policy coverages and does not include all conditions, limitations or exclusions. Please refer to the actual policy forms for detailed coverages, limits and deductibles. • �"� OP ID: .i A �® CERTIFICATE OF LIABILITY INSURANCE DATE(MNYYY) 12/220/10111 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 800-474-0933 CONTACT Richard Janis NAME: Alarm Insurance Agency 800-240-0631 AIC NN Ext): FAX No): 125D Wappoo Creek Dr.,Ste.113 E-MAIL Charleston,SC 29412 ADDRESS: Richard Janis PRODUCER CUSTOMER CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Nightwatch Protection Inc. INSURER A:First Mercury Insurance Co. 10657 50-A Northwestern Drive,Suite INSURER B:Capitol Indemnity 10472 Salem,NH 03079 INSURER C:CNIA Surety 13188 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL TYPE OF INSURANCE B POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 A X COMMERCIAL GENERAL LIABILITY FMM1008513 09/28/11 09/28/12 DAMAGET TED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE Fx_]OCCUR MED EXP(Any one person) $ 5,000 X Errors&Omission PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICYFX PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLALIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY y/N TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVEF-1E.L.EACH ACCIDENT $ D? OFFICER/MEMBER EXCLUDEN/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ B �LP ME TRANSIENT ME 41172492 04130/11 04/30/12 LP ME 10,00 C LP RI$10,000 70760043 07/20111 07/20/12 LP RI 10,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION - TOWONO3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Date. . . .. .. . ... .`.7.. . . . . o� �' ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION � 1 5 �9S SACHUSEtS This certifies that . .-. .-.R.—.-.-.' . . . . . . . has permission for gas installation - -Ik -:. . . .: . . . . . . . . . . . . r< in the buildings of . . . . . . . . . . . . . . . . . . . . . . . at /� .!.f- .:. . ,North Andover, Mass. ov Fed D."t Lic. No/-./ 79 . . .�.!�� . . . . . 'Ar-.'. . . . . . . . . IN�� OR Check 4858 MASSACHUSETTS UNIFORM APPLICATOFOR PERM r TO DO GAS FITTING (Type or print) Date x/22/04 NORTH ANDOVER,MASSACHUSETTS Building Locations 40 Inglewood St. Permit# ___ 7 ��U Joseph Mellucci Owner' ' ame 978 688 7939 Amount New Renovation ❑ Replacement ❑ Plans Submitted ❑ ww a . . .r n In t $30.50 DV -34-S P U cL aWO F O J» zaa Cn O O W it W C OO z Fa O y p. rn O Z O z p a o w 3 a U SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD. FLOOR 4TH . FLOOR 5TH. FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Eastern. Propane Gas Chime k one: Certificate Installing Company Name U Corp Address 131 Water St. , Danve.rs MA 01923 ❑ Partner. Business Telephone 1 800 322 6628 �/� ❑ Firm/Co. __ l%V 1 Name of Licensed Plumber or Gas Fitter 7c,- Acv\ INSURANCE COVERAGE Check e: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ Ifyou have checked yp_s please indicate the type coverage by checking the appropriate box. Liability insurance policy 0 Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: $` ature 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 bsjt 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 Massachusetts State Gas C e n hapter 142Vfthe General Laws. By. Signature of Licensed Plumber Or Gas Fi er ^^ Title ❑ Plumber City/Town Gas Fitter (cense FlumSer ❑ Master APPROVED(OFFICE USE ONLY) ❑ Journeyman I LocationDN No. Date a � — woRTM TOWN OR NORTH ANDOVER f � 3?0�,•``D �_••hOOL M A y Certificate of Occupancy $ yfs'•""'tt�' Building/Frame Permit Fee $ 1 s�CMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ISD Check # /330 15809 Building inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: -f2 DATE ISSUED: X ic SIGNATURE: Building Commissioner/I of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: le. wed�( f7` ll C�`7 /00 .U)ktkve r Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Regaired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Toe ^aLccc('- Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ /*141ee- !-cly4l- d 0 [[� ` Licensed Construction Supervisor: 7� a v .�/ 1111e, �e l k 4 e`1 License Numbermn Address icExpiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Ave , Registration Number` r Address G la;/0 5/ �'u- �a^6`� S Expiration Date !! Signature Telephone Y) SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check au applicable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be ` OOF&'ICIALUSE OleII.Y Completed by permit applicant � � Fw= 1. Building yro O (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Toe '41a (CtA I n as Owner/Authorized Agent of subject property Hereby authorize 5;1 &'t' ��: to act on My behalf,in all matters relative to work authorized by this building permit application. ?&IJ10 a Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 111.4 K C A?IN A r.0 O as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief A /At o Print Name ` Signature of Owner/A ent Date XWA M. NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2 ND 3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DINIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDvWEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name Please Print Name: �}!2 C 1,k)A 1-0 o Location. Z`'�4�p wdoct f'7 city AV- Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Com an name: Address City Phone#: Insurance.Co. Policy# Company name: 11114 le Address Citi /F2 e i/i 6-e K Phone#: Insurance Co. ,,':-/Tc- 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$1,500.00 and/or one years'imprisonment_as welLas_civil.penakiesin-thefcrm.nf-a_STOP WORK ORDER-and_a.fine of-($1-0.0.00)-arJay.againstme, I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. Y I do hereby certify under the pains and penalties of perjury that the information provided above is true and cofrect. / Signature a'u- v— Date / d3/o�- Print name �'� I�Q l o Phone# Official use only do not write in this area to be completed by city or town official City or Town Permit/Licensing Building Dept ❑Check if immediate response is required [I Licensing Board p Selectman's Office Contact person: Phone#: E] Health Department Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Ae7k&ePt -i^a&s Aev- J-Ta?'io ck (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector NORTH Town of Andover 0 No. TT dover, Mass., C!- 0RArED C BOARD OF HEALTH Food/Kitchen r- ERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......10.1�..........jMluck ;............................................... .... Foundation has permission to erect...64 k (P ......... ............ . ............ ............... buildings on ...... .. ..... Rough to be occupied as.......4 ......................... D ... Chimney ....CA-0 ...................................................... provided that the person accepting this permit shall in every respect conform t the terms of the application on file in Final this office, and to the provisions of the Codes and By- y ws relating e Inspection, Alteration and Construction of R Buildings in the Town of North Andover. 1P PLUMBING INSPECTOR As;p VIOLATION of the Zoning or Building Regulations Vbids this Permit. Rough PERMIT- EXPIRES N 6 MONTHS Final UNLESS CONSTRUCTION S ELECTRICAL INSPECTOR Roughgh ...... .. ... ......................... - INSPECTOR; Service i BUILDING Final Occupancy PermitRequired: to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPART.MENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.