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Miscellaneous - 433 WAVERLY ROAD 4/30/2018
x -- slow Datel- -/'- '4 ........................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING .......... This certifies that .... ................. ......... ................................ has permission to perform ........ > ............................................ ................. wiring in the building 00.-'�.4.--'A ...................................................... . ........... ... ... ...... at .................................. .... Ao . .......... ........... . North Andover, Mass. Pf . / 3 ......... '. -. W, .. Lic. ........ -)2: o Fee.... N ...... ....... ......... I .......... I ELEc-mcAVINsp R Check # V 6c 39 0246 Date .... //. -. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ................ ....................................................................... has permission to perform ....... .......... wiring in the building of ................... ..................... 42132 0�' at ........................ ..................... North Andover, Mass. ...... .... ............. ic. No. Fee.:7:57 ........... L ECrRICAL I�S�ECT�j('�t Check # 2U12 Massachusetts Electrical Code Amendments 527 CAM 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the on the prescribed forin. After a permit application has been accepted by an Inspector of Wires appointed pursu permit application form to provide notice ofinstallation ofwiring shall be uniforin throughout the Commonwealth, and applications shall be filed ant to M. G.L c. 166, § 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 notification of completion ofthe work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time ofongoing construction activity� and may be -deemed -by. the Jnspector-of-Wires abandoned-and-iny-alid-ifhe—. 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 oftime for completion ofwork shall be pennittec; for reasonable cause. A permit shall be terminated upon the written request ofeither the owner or the installing entity stated on the pennit application. . El The Permit Extension Act was created by Section 173 ofChapLer 240 ofthe Acts of20lO and extended by Sections.74 and 75 ofChapter 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 finthers; this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development ofreal 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 extendin oug An 15,2012. 4 gthr h gust );&Ule8—PermitAD.ate Closed:. Note: Reap'ply for new permitfg:r 0 Permit Extension Act — PermitA[)ate Closed: -A Commonwealth ol i�laeeacku�e Official Use Only c� 0 Permit No. lip1 0 ?,--L aLJeparEmzn� o ire �ervice� '" 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 INFORMATION) Date: ? / q 1/t City or Town of: W o r+- , A rJ o r X To theIn pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 0. j 2 X - Owner or Tenant C h e r V Q a�� �,r Telephone No. q l8 )�$ n Owner's Address P- 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 ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Install residential security system Cmmnlvtinn nfthe fnllnwina tnhlo — be ,e,ni„ad 1 , fl,a 1-..--. -idt;, 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- ❑ rnd. rnd. o. o mergency Lighting Batter Units No. of Receptacle Outle s No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of 'Alerting Devices No. of Waste Disposers Heat Pum Totals: P Number """'' Tons """"""' KW --.-'..............Detection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water Kms, Heaters Heating Appliances KW No. of No. of Si ns Ballasts Security Systems:* L No. of Devices or Equivalent S Data Wiring: 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: 4 Cj (When required by municipal policy.) Work to Start: a I I I I 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. LIC. NO.: 7 0 2 4 C Licensee: Paul DelSignor SignatureD.J1LIC. NO.: 7 0 2 4 C (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: $ S s v s C) CL W 'O 0 f/1 3 A Q O O 0 o D. (A cn 3 CD o00 �• .CD V_ 00 op CC a w .0 1 Cil t N H�z �.0 O N � x � O y \ Vm �ro s C) CL W 'O 0 f/1 3 A Q O O 0 o D. (A cn 3 CD o00 �• .CD V_ 00 op Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 9/051 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 LL NF RMATION) Date: k 3 --0-6City or Town of: n�p./ e-,/ To the Inspector of Wires: By this application the undersigned gives notice of his or her intention o lzerform the electrical work described below. Location (Street 9;--� V to Vt\J3 % - 116 If - y ly y 7-3 qy�wn r enanot eV iA K Telephone No. Owner's Address s Is this permit in conjunction with a building permit? Yes No El (Check Appropriate Box) Purpose of BuildingV 0 ,\ i + �%,A �_0 Utility Authorization No. 110 YD 6q Existing Service A/14 Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service c)942 Amps t /2�'WVolts Overhead ❑ Undgrd)o No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:�- Completion of the following table may he waived by the ingnoctnr of Wirac No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. El In- ❑ o. o Emergency Lighting Units No. of Receptacle Outlets No. of Oil Burners -Battery FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals Number Tons K No. o elf -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. o Water KW Heaters No. o No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP elecommunications 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.) Work to Start: Oho 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 1�' BOND ❑ OTHER ❑ (Specify:) I certify, under the pains an a alties ofpe , thaie inflrmation on this application is true and complete. FIRM NAME: ✓p j y�e Ii LIC. NO.: Licensee: �v Signature LIC. NO.: (If applicable enter" xempt" in the lic se number line.) �( ' ( Bus. Tel. No.: Address: �S ,� 1Veo"M-/ Alt. Tel. No. J�3 *Security System Contractor License required f6f this work; if applicable, enter the license number here: 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: $ 37--06 fes' 5,Fk r,644,tO ate. Location 33�!' No. L1 2 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ S Mu Building/Frame Permit Fee $ 13L Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 3 17926 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT EF,RYbNOVA OR DEMOLISH A ONE OR TWO FAMILY DWELUNG BUILDING PERMIT NUAfER: DATE ISSUED: Lcla2 Q SIGNATURE: Com'`-'' Building Cotnn-dssioner/12gwor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 333 Waverly Rd North Andover, MA 01845 1.2 Assessors Map and Parol Number: ( i MaP Number Parcel Number 13 Zoning Information: 4 Residential Zoining District Pr Use 1.4 Property Dimensions: 10,723 s.f. 180 Lat Area Frrntn ft 1.6 BUn DING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided red Provided 1 4.7 weber Supply M.O.LC.40. 54) 1.3. Fuad Zoos Iafoxmrrirn: Public 0 Private ❑ zowe Oadide Flood Zane ❑ l't Sewowje Dirp 1 Sydem: Mankipal ❑ on site Diapow Syst= ❑ SECTION 2 - PROPER Y OWNERSHIP/AUTHORIZED AGENT , i strict: %, NO 2.1 Owner of Record Patrick Streck 4,-333 Waverly Rd. Namekgnt)Y Address for Service: 978-258-9788 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: -Signature Tele bane SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature, Telephone Not Applicable License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable o Company Name Registration Number Address Expiration Date Si afore Te! hone 00 M Z 0 0 M �.J a z M 0 a r 0 M r r r�ra z 0 SECTION 4 - WORKERS COMPENSATION (KG.L C 152 $ 25c(6) Workers Compensation Insurance affidavit must be.completod and submitted with this application. Failure to provide this affidavit will result -in the denial of the issuance of the buildin it. Si ed affidavit Attaohod Yes .......0 No ....... 11 SECTION S Descri tion of Pruposed Workckww&k d New Construction 0 Existing Building 0 Repair(s) 0 Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify , Brief Description of Proposed Work: Build out second floor (currently empty attic) to include two (2) bedrooms and one (1) bathroom. SECTION 6 - ESTEMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by perrruit applicant a1 VIC>EA , IF]}ffi ONLY" 1. Building N it to (a) Building Permit Fee Maid lier 2 Electrical ✓ 1 LAMS (b) Estimated Total Cost of Construction 3 Plum i • -� Building Permit fee (+) x (b) d��---- / 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 L- 14 Check Number SECTION 7s OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Patrick Streck�(, asAuthorized Agent of subject property Hereby a raze John Mansur to act on MY 1 11 tette a -to work authorized by this building permit application, Sr lature of Owner Date l�C� SECTION 7h OWNER/AUTHORIZED AGENT DECLARATION 1, Patrick Stre ck 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 Patrick Streck Print N 1�` Si tune of Owner/ ent Date 1 TORIES Sim BASEMENT R SLA13 S R TIMBERS I 2' 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDA'T'ION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE L 2 O M co cy 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: -- (Location of Facility) Signature of Permit Applicant _ (2 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector D. Robert Nicetta, Building Commissioner Please print TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 HOMEOWNER LICENSE EXEMPTION Telephone (978) 688-95454 Fax (978)688-9542 DATE: VZ ( zo 1,51+ JOB LOCATION: 333 M9Q.A RD. 11 ,3 ,6 Number Street Address Map/Lot HOMEOWNER ?A%44 316a 4' 6 -20-MO 791- W1.-?ZC Name Home Phone Work Phone PRESENT MAILING ADDRESS 333 k/AVO2l t.I Q. Nom "OV., M a18K City Town State . Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings to two units or less and to allow such homeowners to engage anindividual for hire who does not possess a license, provided that the owner acts as supervisor). State Building (Code Section 108.3.5.1) DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family structures. A person who constructs more that one home in a two-year period shall not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other Applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. _ HOMEOWNERS SIGNATURE APPROVAL OF BUILDING OFFICIAL BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 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 or requirements. APPLICANT FILLS OUT THIS SECTIONS************ APPLICANT 9Mak 5-MaK PHONE 48'26-6 Oft LOCATION: Assessors Map Number / + PARCEL J SUBDIVISION LOT (S) STREET_k1NOQl.�( ( ST. NUMBER 333 OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT IRE C RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 Jm (t V" 1,42/a/ o y i rA v N� M -V • -b Z O D I y h E CDCL O Q cc M CA O CL y O V m L iGs CLy G G3 CM C CIO m ■ C c MEGO is LLI Y/ 19 W LLI W od 0 o a a h A v U A J aC O C U m = O o� A Ea w : �md w w Uw" a oG ir. a w w" N E5 z r�4 c-Old rs. co z cn cn v N� M -V • -b Z O D I y h E CDCL O Q cc M CA O CL y O V m L iGs CLy G G3 CM C CIO m ■ C c MEGO is LLI Y/ 19 W LLI W 0 o �o� h a� J aC O C m = O o� Ea : �md 3 a N E5 z 3cm fti mc_ E CO V �y N m / O a =C C In O O Em v mmwo at wCc = m o INC :yc= o C 7 m 0 oa S Z Ci.. C ` CL co = m 4DL p N COD Go C ++ w Lu CL c 103 10 Z a 5 CO2 Go ID_o1 agm= s = arm F v N� M -V • -b Z O D I y h E CDCL O Q cc M CA O CL y O V m L iGs CLy G G3 CM C CIO m ■ C c MEGO is LLI Y/ 19 W LLI W - I I " I, F I Date.'�' ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION , I Y.7 This certifies that .............. .................. has permission for gas- installation ......... .................. in the buildings of'�'.' ........... at .................. North Andover, Mass. ...... Lic. No.. ......... /"�'OAS INSI��CVR Dept. PINK: Treasurer WHITE: Applicant CANARY: Buildin vIASSACHUSETTS UNITFORM APPLICATON FOR PERMIT TO DO GAS or print) twccI H ANDOVER, MASSACHUSETTS Building Locations Owner's Mame New Renovation ❑ Replacement ❑ Date /-,Q- — 7 — I® Permit 9 Amount S 5 Tt✓`c., S /4Q �G Plans Submitted ❑ (Print or Name_ Address - U 6I �, Check one: Certificate Installing Company ,c- f� � 1 d. � iL ❑ Corp. b',wJC.,d L ti pep ❑ Partner /Ue Uj .0 Business Telephone (off 3 3 Name 'Oif Licensed Plumber or Gas Fitter '7 ❑ FirmiCo. INSUR, INCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ves. please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond E7 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 ❑ I herebv certifvthat all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations pertormed under Permit Issued for this application will be in compliance with all pertinent provisions of the :Massa setts State Gas Co�and Char 142 of the Gene. -al Laws. By: Title City/Town APPROVED IUFPICii IJSE')NI,Y) Sienature of Licensed Plumber Or Gas Fitter Plumber ❑ Gas Fitter Ic: nse ;vumoe: j Ivlasier L❑1 Journeyman 7j Date. 4�. .' ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation I ................. in the buildings of ................................... at.............. North Andover, Mass. Fee.......... Lic. No ........... ............ GAS -INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS r � Date Building Location �4 Owners Name r ? Permit `4W t Amdt Type of Occupancy New Renovation Replacement El Plans Submitted, eY s r-1 No F (�rint or type) CCCheck one: 16stalling Company Name P12C11fJ `e. �"/�rJ' Corp. _ J A0dress Partner. 3 �ST Business Telephone �� p �g �'a '7 02 11 Firm/Co. Name ofLicensed Plumber. /1 id K,,P;V /V.,0V <, Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity R Bond ❑ Certificate Insurance Waiver- I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the chusetts State P� bing Gc de a /f�Qpter 14 of the General Laws. ,Title A64 Type of Plumbing License City/Town icense um er Master Journeyman 0 APPROVED (OFFICE USE ONLY a •M ..., cs • mmmmmmmmMMOMMMMOMMMMMMM��MMMMMMMWMMMMWMWMMMMM115 MMMMMMMMMMWMMMMMMWMMMMMMMMMMMMMMMMMWMMMMMMMMMMMMMMM130 MMMMWW0MMMMMMMMMW0MMMMMM (�rint or type) CCCheck one: 16stalling Company Name P12C11fJ `e. �"/�rJ' Corp. _ J A0dress Partner. 3 �ST Business Telephone �� p �g �'a '7 02 11 Firm/Co. Name ofLicensed Plumber. /1 id K,,P;V /V.,0V <, Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity R Bond ❑ Certificate Insurance Waiver- I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the chusetts State P� bing Gc de a /f�Qpter 14 of the General Laws. ,Title A64 Type of Plumbing License City/Town icense um er Master Journeyman 0 APPROVED (OFFICE USE ONLY NORTFf '9 O �11.10 16y O O� c% ey of 4111, O" 'c coc�«.w[. A�RAttso APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY: ` J3 V 6'G� DATE REQUESTED FILED/READY FOR INSPECTION CLOSING DATE ON PROPERTY: S-` l/ 0/ FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE-,STRUCTURE.DOE"OT MEET ALL APPLICABLE CODES. SIGNED It le ROUTING CONSERVATION PLANNING DPW - WATER METER NOTE ❑ De- (,du) s -!-D/ DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST A iw nature File: OC form revised 618198 S-4-0 16 M co INS LLJ 7CL wa P - a a: wC h O w° vii ° ° U w rL p, C o i�. 0.4, z Q J4 o o w w cn cn LLJ 7CL y �C tdmb E too D .mc E y c Q� `� CDCIE COX: ma A =sc C C C�tiy, cc _O y r0 O O 0 OD S ` � COOS Q no �° Z o ... of m aC" D LU O � �,, C s. •� .y § w W C Z .m v m .0 C C4 m� O� R W m H= 0 �- j�4-m a 0 4 wC h O rL p, C RD ca0096 on y �C tdmb E too D .mc E y c Q� `� CDCIE COX: ma A =sc C C C�tiy, cc _O y r0 O O 0 OD S ` � COOS Q no �° Z o ... of m aC" D LU O � �,, C s. •� .y § w W C Z .m v m .0 C C4 m� O� R W m H= 0 �- j�4-m a 0 4 Location 11110 W A UEP I Y /?c� S�3 Date ORTN TOWN OF NORTH ANDOVER AL Certificate of Occupancy $ Arso CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee T,�Zpk-ZL $ TOTAL $ Check # 51 2 'Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE pyeO�R TWO FAMILY DWELLING •5&Y'" �£'b^ �., roi'^.o- _ ' V wf�' G�.,.,bk..sF.es'�"�''rs"`'r��ii�%Xffi'`�"�s",°:: BUILDING PERMIT NUMBER: ` DATE IS=SUED- '77 SSUED: C� SIGNATURE: Building Conunissioner/I for of Buildings Date I ar,%-IIU1\ 1-a11L, 1111l»UNMA1`1UIN • i' • . . 1.1 Property Address: Y.3.3 l�li�.ye��e v r�! 1.2 Assessors Map and Parcel Map Number Number: - • . Parcel Number ' 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas - Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Re red Provided 1 1.7 Water Supply M.G.L.C.40. 54) Public ❑ Private ❑ 1.5. Flood Zone Information: Zone Outside Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTIUN 2 - PKOPERI'Y OWNEKSIIW/AUTHORIZED AGENT 2.1 Owner of -Record y0 Y 33 ova d�� Name nt) Address for Service -signatpfe Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed doFnstruction Supervisor:C /10 s, License Number E ess 7 ?5-411 / /Expiration Date Si ature Telephone 3.2 Registered Home Improvement Contractor Not ApplicabP ❑ Company Name Registration Number Address Expiration Date Signature Telephone SECTION 4 - WORKERS COMPENSATION (KG.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Descrition of Proposed Work(check all a Ucable New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition Other 0 Specify Brief Description of Proposed Work: // 4 - dA az n X•-ee.S7�ti�i i70 .2.� �' �.Z. a1GGK OL' Gy0 0 O� �Q /`a t �e SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant r ,., ` dFFICIAL USE;UNLY a: 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (@) 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 CONTRACTORAPPLIES FOR BUILDING PERMIT I G( as Owner/Authorized Agent of subject property Her�autho'e Jam to act on Hel m rs rel a to authorized by this building permit application. � >-a/ Si ature of Owner Date SECTION 7b OLWNER/AUTHORIZED AGENT DECLARATION I, �/`G�'/t� �m d K ,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 S S Print N e TO Si at o Omer/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 SPAN DM ENSIONS OF SILLS DIN ENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHMdNEY IS BUILDING ON SOLID OR FII. LED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover Building Department 27 Charles Street North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542 Building Demolition Affidavit DATE / 7 0 s e.,d,e pORTFf q O �t�eo rs• �O OL F- ~ '9� COC MKN�wKR . 7' .S� o /'f", e'' /00 7" CONTRACTORS NAME & ADDRESS ,-CZyC U da, 1 Oyt ✓lii v,P�li/.r �� %�Cc O / �' 5� w / y� DEPARTMENT SIGN -OFFS D.P.W./ WATER /v` /T. SEWER TELEPHONE 4 6q CABLE TAXES POLICE FIRE EXTERMINATOR Z DIG SAFE NUMBER -496406' 4-/V 0 / BLDG. INSPECTOR DATE RECD Town of North Andover & tAaRTH O LED � t Building Department 0 r 27 Charles Street North Andover, Massachusetts 01845 m (978) 688-9545 Fax (978) 688-9542 9 `°`~`~'w~• �` ��SS�,c�►us���y DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: Facility location Signature of Applicant 2 -7-6v Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. ACERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 02/07/2001 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION POLICY NUMBER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE INTERNET INSURANCE AGENCY INC. 522 CHICKERING ROAD HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. rAN NORTH ANDOVER, MA 01845 INSURERS AFFORDING COVERAGE INSURED INSURERA: EASTERN CASUALTY STEVEN SMOLAK INSURER B: ASSOCIATED INDUSTRIES OF MASS MUTUAL INSURER C: 762 DALE STREET INSURER D: NORTH ANDOVER MA 01845— INSURER E: PRODUCTS - COMP/OPAGG $ 5,000 COVERAGES 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 CSRS•—•—A—E HOLDER MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATIONIDDI LIMITS rAN GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY ❑ CLAIMS MADE ❑❑ OCCUR ❑ CP0000227 05/01/2000 05/01/2001 EACH OCCURRENCE $ 2,000,000 FIRE DAMAGE (Anyone fire) $ 2,000,000 MED EXP (Any one person) $ 1,000,000 BADV INJURY $ 1,000,000 ❑ -PERSONAL GENERAL AGGREGATE $ 50,000 GEN'L AGGREGATE LIMIT APPLIES PER: RO ❑ LOC 13 POLICY ❑ PEC PRODUCTS - COMP/OPAGG $ 5,000 AUTOMOBILE ❑ LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ ❑ ❑ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) ❑ ❑ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ ❑ PROPERTY DAMAGE $ (Per accident) ❑ GARAGE LIABILITY ❑ ANY AUTO ❑ AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY ❑ OCCUR 7 CLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DEDUCTIBLE ❑ RETENTION $ $ $ WORKERS COMPENSATION AND WC STATUS OF R B EMPLOYERS' LIABILITY VWC6002880012000 12/27/2000 12/27/2001 E.L. EACH ACCIDENT $ 100,000 E.L. DISEASE -EA EMPLOYE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ^ I I__I 1 ADDITIONAL INSURED; INSURER LETTER: CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 120 MAIN STREET DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR NORTH ANDOVER MA 01845— REPRESENTATIV ACORD 25-S (7197) ILGACORD CORPORATION 1988 C/) m C/) 0 m COD CD a Z CD O d CD O � CL CD o w Up C� CD CL o CD CO) 'O CD a O LrJ y .0 d -d O CA C!. 0 CO) Ma go CD O CD CD 3, CO2 CD CO) 0 CCD 0 CD O 0 a H _ d 0 S. m CO) » C m Z y 0 a 0 �, = =r -c H o, � CL CL CO -1 0 m y 0 CO) N 0 ••►'O_ gym: CA -00 ® c 0 d d c� O O y � JU � G X� �f=q� 1�� d CL 0 or m n 'my� N 0, .4w z�< cn CA cn Paz i 0 0� m O v0 �1 O o ;at Z y mcm Z tx cm coCD : +� 1 VJ C/) W _� d � 0� a w'y Iv m C/) 0 cn �,^p� rt M y n] � Z �p - ;;j r. m co p 7d Z F b O� ',3',1 n 'Jd 'z7 ro Cn d `t7 all- tv tv x 101 N2 7 Of 40RT#t * I t4 6 7-'A 0 Date....// .............................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................... i.—� ....... .. . ... has nermission to nerform .............................................................................. wiring in the building of ............. .................... ....................................... at .......................... ...................... North Andover, Mass. Fee: ........... ............ Lic. No . ............. .... Check '0 ////2 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer DEPARTMENT OFPUBLICS4FETY BOARD OFFIREPREYElVI7ONREGUL4T10AN527CMR 12-00 19 Permit No. C> Occupancy &Fees Checked APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 2-3 " VL Owner or Tenant ,� f Ey� -S %) ©LG Owner's Address %G i-)r-t/L Jfl Is this permit in conjunction wit(h'a building permiit:' I Yes No Purpose of Building Existing Service Amps/ Volts New Service Amps 145-1 3OVolts (Check Appropriate Box) Overhead Underground Overhead © Underground Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Utility Authorization No. No. of Meters No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVAKVA No. of Lighting Fixtures Swimming Pool Above Elground Below Generators ground No. of Receptacle Outlets 4 No. of Oil Bumers No. of Emergency Lighting Battery Units No. of Switch Outlets 116 No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges �CS No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal, Other No. of Dryers / Heating Devices KW AA -b Connections a No. of Water Heaters KW No. of No. of Signs Bailasis Hydro Massage Tubs No. of Motors Total HP OTHER Work to Soft Sid utxieM FIRM NAME( Lioa>s� �•J le A1 C J "- EVirAm Dai Est Vakxd lmft%al Wade $ Ro# Final LioetseN I at Bt"mTei Na 603 OWNER'SINSURANCEWANER,Iamawar dWtheLiox sedommhmtheltum=wv-a a-itsab Mnbalapy,d lasmgmWby CalaaiLaws "dutmysigt �tuecn this peantapphcmm wain this rr�snOt (Please check one) Owner Agent Telephone No. PERMIT FEE $ V33 LVAUERZ Location - / " No. 5 -Ll �. AP Jc� IQ 9A - Date TOWN OF NORTH ANDOVER ili�g& Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ 0 Other Permit Fee $ TOTAL $ Check # 1 4r' 45 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLINGw _ 1} BUILDING PERNUT NUMBER: R DATE ISSUED: SIGNATURE. /vie Buildin Commissioner/In ctor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: S�� Zoning Di 'd Pr6posed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUrLDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Rred Provided Required Provided r 1.7 Water ;7j;,M.G.L.C.40. Public ivate ❑ 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Zone Outside Flood Zone D Municipal Xi"', OnSiteDisposal System ❑ SEC I WIN 2 - PROPERTY Y OWWiNERSIFw/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Cons uction Supervisor: A Not Applicable ❑ Licensed Cfonstruction Supervisor: j_ Z ef'/: License Number Addre 7 Expiration Date Signatu Telephone 3.2 Registered Home provement Contractor Not Applicable ❑ 627 Company Name 77 / e / Registration Number Addr s Expiration Date S na WrT Telephone SECTION 4 - WORKERS COMPENSATION (AG.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 ....... 0 SECTION 5 Descrin of Proposed Work check all applicable) New Construction V Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition ❑ Accessory Bldg. 0 Demolition ❑ Other 0 Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by pernut applicant QMCIAL;USE ONLY 1. Building (a) Building Permit Fee Multiplier (0 S 2 Electrical �� (b) Estimated Total Cost of Construction j �n 7 - / 0 3 Plumbing 60 d Building Permit fee (e) x (b) 4 Mechanical (HVAC) 0 0 d 5 Fire Protection 6 Total (1+2+3+4+5) Ci p Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building pemut application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, =1'� i'`��i �G✓�,� as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name '�._ --� 7 �^ Si attire f Own A ent Date NO. OF STORIES 2_ SIZE BASEMENT OR SLAB 04 r 0 - SIZE OF FLOOR TIMBERS (J 1 / 2 ND 3 RD SPAN °e DIMENSIONS OF SILLS ` , -4 DIMENSIONS OF POSTS ZJ DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS /O' SIZE OF FOOTING / ' X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND ISBUILDING CONNECTED TO NATURAL GAS LINE k FORM - U - LOT RELEASE FORM ���� ® 0 INSTRUCTIONS: This form is used to verify that all -necessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT%/e�4 _� /�, `� PHONE 9 7(??r f ASSESSORS MAP NUMBER LOT NUMBER 4Z SUBDIVISION NUMBER "t -% C STREET STREET NUMBER d / ........................ .................................................. OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS A"n 1 -19. DATE APPROVED CONSERVATION ADMINISTRATOR /DATE REJECTED CONMIENTS % BI" UI^( ` �✓ �� I< ° DATE APPROVED g &6- /w DATE REJECTED COMMENTS `�'�IV/YL_ /-f U' li�( 4 DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED CON ENTS DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with the provisions. : of MGL -c-'40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a property licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Location of Facility Signature off�ern-jit Applicant C2 Date NOTE: Demolition permit t from the Town of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Nlassachusetts Department of Industrial -Ac -,,dents OF, .of Investigations Boston, Mass. 02 111 Worker.;' Compensarion Insurance ATIdavit blame Flease Frim ill Ci`'/ Phone T I am a hcme�, nor perrcrminc all work myself. I am a sole proprietor and have no one working in any capac:t,/ W` c0 owl—p;7 CI am an emproviding workers' compensation femy employees wcrkine on this job. e CiN: Phcne T: r l Comcanv name: Address Pclicv T Cihi: Phone r' Insurance Co. Failure to sec :re coverage as recuirac under Section 2SA or itMGL 15_ can lead to the imecsition er c imiral penalties cf a Rne up to S1, SCO.CO and/or one years' impriscrment as -,veil as c:vii penalties in the form cf a STCP'P/CRK CIPCE" and a rine cf (S100.00) a day against me. I understand that a cdpy d this statement may to fcrvarded to the Office cf Invesagaticns cf the GIA fcr coverage verincaticn. 1 do herebycelunc rext;es or pe:7 that 'h of , ,aticn provided accve rs 'rue and ccrrec;. SicnaturDate r/d do Print name 4 Fhcne #r Ls Ofn`c:al use only do not write in this area to to completed by c: -,y cr tcwn cfr:ciai City or Town Permit/Ucensirc ❑ Building Dept ❑C`ec4 if immediate response is required [] L'censinQ Board Selectman's J ltcc- Contac; Ferscn: Phcne ; C health Department other GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVERBUILDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the necessary information as requested below. Permit Applicant Property address Ma /Parcel f �� Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the building permit. Further I understand that my interpretation of the exemption status is subject to review by the Building Department and is only officially accepted when the building permit is issued. Based on section 8.7.6 ofthe North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement, restoration or reconstruction of a dwelling in existence as of the effective date ofthis bylaw, provided that no additional residential unit is created. The lot(s) was / were created prior to May 6, 1996 and are exempt from the provisions of section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and or moderate income families or individuals, where all of the conditions of 8.7.6 are and and or represents dwelling units for senior residents, where occupancy of the units is restricted to senior citizens through a properly executed and recorded deed restriction running with the land. For purposes of this section "senior" shall mean persons over the age of 55. This application is part of a development project which voluntarily agreed density (buildable lots) below the density permitted under zoning and feasito a minimum 40 %permanent reduction in ble given the environmental conditions of the tract, with the surplus land equal to at least tar buildable acres and permanently designated as open space or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the planning board that will assure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a onetime exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot which is ready for a building permit ( all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that year. One building permit will be issued per year per Development until such time as the development schedule accommodates issuing building permits. Applicant must submit an approved FORM U with this EXEMPTION. PLEASE PROVIDE ANY AND ALL INFORMATION THAT WOULD ASSISTTHE BUILDING DEPARTMENT IN MAKING A DETERMINATION THAT THIS APPLICATION IS ALLOWED UNDER ONE OR MORE OF THE ABOVE EXEMPTIONS. BY SIGNING BELOW I ATTEST TO THE ACCURACY OF THE INFORMATION PROVIDED AND THAT THE ATTACHED BUILDING PERMIT IS ALLOWED AN EXEMPTION AS CITED ABOVE. FURTHER I UNDERSTAND THAT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE CHECKING OFF OF A ABOVE EXEMPTION WH H DOES NOT COMPLY, WHETHER DONE TO MY KNOWLEDGE OR NOT IS ROUNDS OR REFUSAL By HE B D DEPARTMENT TO ISSUE A BUILDING PERMIT. AP LIC S SIGNATURE THIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICADA TION J.VVILLIAM HMURCIAK, P.E. DIRECTOR TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET, 01845 Telephone (978) 685-0950 Fax (978) 688-9573 LEO � DRIVEWAY PERMIT DATE A,- a000 LOCATION }�t Uc r /tea BUILDER hone OWNER 121�e ��pim® � to l hone - �! 1 ��S � THE NORTH ANDOVER SUPERINTENDENT OF OPERATIONS MUST BE NOTIFIED OF THE GRADE AND SETBACK FROM STREET. CALL THE SUPERINTENDENT'S OFFICE BEFORE FINISH GRADING AND SURFACING FOR SUCH ENTRY. APPROVAL OF FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. 1569 APPLICATION FOR SEWER SERVICE CONNECTION 2X-0 North Andover, Mass. 44 Application by the undersigned is hereby made to connect with the town sewer main in subject to the rules and regulations of the Division ofPublic a6?c WorksJThe premises are known as No. —1 ©( (/ e- �[ or subdivision lot no. /2 V Street S ?6 2 Pa10�04 61�� Owner Address Contractor Address p I Signature PERMIT TO CONNECT WITH SEWER MAIN The Division of Public Works hereby grants permission to t+e P �e, I to make a connection with the sewer main at J/V R '� subject to the rules and regulations of the Division of Public Works.. Inspected by Date V rd 5 Street Division f Public Works U By See back for rules and regulations 4ree� p eo ', t RULES AND REGULATIONS FOR GOVERNING THE INSTALLATION OF SEWER SERVICES 1. No unauthorized person shall uncover, make any connections with or opening into, use, alter, or disturb any public sewer or appurtenance thereof without first obtaining a written permit from the Division of Public Works. 2. All costs and expense incident to the installation and connections of the building sewer shall be borne by the owner. The owner shall indemnify the (town) from any loss or damage that may directly or indirectly be occasioned by the installation of the building sewer. 3. A separate and independent building sewer shall be provided for every building; except where one building stands at the rear of another on an interior lot and no private sewer is available or can be constructed to the rear building through an adjoining alley, court, yard, or driveway, the building sewer from the front building may be extended to the rear building and the whole considered as one building sewer. 4. Old building sewers may be used in connection with new buildings only when they are found, on examination and test by the (Superintendent), to meet all requirements of this ordinance. 5. The size, slope, alignment, materials of construction of a building sewer, and the methods to be used in excavating, placing of the pipe, jointing, testing, and backfilling the trench, shall all conform to the following requirements. The sewer shall be 6"diameter SDR 35, PVC pipe. Minimum slope shall be 1/8" per foot. The minimum depth of sewer shall be four feet below finish grade. Sewer pipe shall be installed on a stable trench bottom of hard durable crushed stone to a minimum (6) inch depth below the pipe. After the pipe has been installed, crushed stone shall be brought up to the crown of the pipe. Care shall be taken to carefully grade and compact the stone, and prevent pipe displacement. The remainder of the trench shall then be backfilled in one foot lifts with mechanical tamping after each lift. 6. Whenever possible, the building sewer shall be brought to the building at an elevation below the basement floor. In all buildings in which any building drain is too low to permit gravity flow to the public sewer, sanitary sewage carried by such building drain shall be lifted by an approved means and discharged to the building sewer. 7. No person shall make connection of roof downspouts, exterior foundation drains, or other sources of surface runoff or ground water to a building drain which in turn is connected directly or indirectly to a public sanitary sewer. 8. The applicant for the building sewer permit shall notify the (Superintendent) when the building sewer is ready for inspection and connection to the public sewer. The connection shall be made under the supervision of the (Superintendent) or his representative. 9. All excavations for building sewer installation shall be adequately guarded with barricades and lights so as to protect the public from hazard. Streets, sidewalks, parkways, and other public property disturbed in the course of the work shall be restored in a manner satisfactory to the (town). 1007 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. J Application by the undersigned is hereby made to connect with the town water main in U Ja Ue-1 a Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No.4P atl& � �� Street or subdivision lot no. z V 14 / ':;�e 4 64 o -7� Z 1 a J Owner Address 11 Contractor Address -v s App icant'v ignature bus: ao PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the water main at IN vel subject to the rules and regulations of the Division of Public Works. Inspected by Date /0' Street Board of Public Works By See back for rules and regulations - ree. ® o r Lr ,Qo(- I00y1 4 RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be 1" type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4'/i foot rod and brass plug type cover. ?, ' ''' r ` ✓fie �omvr�w�uuealCfi 4�✓�caada,�,fucaeCia j BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 053176 Birthdate: 02/15%1958 Expires: 02/15/2001 Tr. no: 7046 -. Restricted To: 00 STEPHEN M SMOLAK _ 762 DALE ST«�, NO ANDOVER, MA 01845 Administrator 3 O� a� w CIS o #ag �� FMa coo a) 0 r w3 Q ] O Z F_I Y= O = E a)`V L a C QOfQ : O V d fl (p uQ LJL C �: .L+ a .0 ma S f f• j; God Q• O C ++ D y U1 '11 O.L ,,F * * '� /rc 3.0 p . C 3 01• °' '3 y o a O AHC c ,. 0 O O O u a m c0 'p E 'D a �11 O 0 d aj om v _c aLL. E -0 aQ a m�•� � 5 - 0 ro L. m C ai W 2 H v G) '^ a C o� c W ay c O 0 a V N LL n W �'tn troy c o .� z a Q gL O Ln L Ln ;� H m D O b W Cd LU 2 ' C 'C5 O o O N V_C O V evc o :m o c T : E< c • +' m c CD Y• m c� E aim m N uo y C C �: E O cm N m '> CC �'t... Q C O Qf C ..o N ' : acs cc o2 m O:CyZ .: c a o cm Q L �. ti .m c 'c . 2 O a: 03 N �- o H LL - .y O �' O C Z LU �E c, a. H o gVi n m� 00 = A .a V H = C) H t $ n$m T 9 CD 0 O Z O D y CDM co L- CL O 0 O 0 Q ra7 CO2 O C..i CO2 c 0 V .0 C. y r-7 L 0 IsCO CO)CL C CO CM C O C D � Co M m LU _0 U) LLI w w crw LLI U) p O a H w w° cgi w2 P2 v U ci w O pG C w E O w w" cG ro w G m' cn c cn LU 2 ' C 'C5 O o O N V_C O V evc o :m o c T : E< c • +' m c CD Y• m c� E aim m N uo y C C �: E O cm N m '> CC �'t... Q C O Qf C ..o N ' : acs cc o2 m O:CyZ .: c a o cm Q L �. ti .m c 'c . 2 O a: 03 N �- o H LL - .y O �' O C Z LU �E c, a. H o gVi n m� 00 = A .a V H = C) H t $ n$m T 9 CD 0 O Z O D y CDM co L- CL O 0 O 0 Q ra7 CO2 O C..i CO2 c 0 V .0 C. y r-7 L 0 IsCO CO)CL C CO CM C O C D � Co M m LU _0 U) LLI w w crw LLI U) MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck software version 2.01 Release 3 TITLE: Classic House Plan: 5-56/12744 CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 8-4-2000 PROJECT INFORMATION: 26 x 36 Colonial - 1,976 sq. ft. COMPANY INFORMATION: Smolak Builders 978.685.4141 NOTES: RIVCO "Town & Country" window units COMPLIANCE: Passes Maximum UA = 327 Your Home = 326 Permit # Checked by/Date The heating load for this building, and the cooling load if appropriate, has been determined using the applicable standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the desi load as specified in Sections 780CMR 1310 and J4.4. -7,4 Builde Area or Cavity Cont. Glazing/Door ------------------------------------------------------------------------------ Perimeter R -Value R -Value U -Value UA CEILINGS 936 30.0 0.0 33 WALLS: Wood Frame, 16" O.C. 1768 13.0 0.0 145 GLAZING: Windows or Doors 194 0.380 74 GLAZING: Windows or Doors 13 0.560 7 GLAZING: Windows or Doors 20 0.560 11 DOORS 20 0.350 7 DOORS 33 0.540 18 FLOORS: Over Unconditioned Space 936 30.0 0.0 31 HVAC EQUIPMENT: Boiler, 82.0 AFUE ------------------------------------------------------------------------------ COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the desi load as specified in Sections 780CMR 1310 and J4.4. -7,4 Builde TITLE: Classic House Plan: S-56/12744 MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck software version 2.01 Release 3 DATE: 8-4-2000 Bldg. Dept. Use [ ] [ ] [ ] C] [ ] [ ] [ ] [ ] [ ] CEILINGS: 1. R-30 Comments/Locatio WALLS: 1. Wood Frame, 16" O.C., R-13 Comments/Location WINDOWS AND GLASS DOORS: 1. U -value: 0.38 For windows without labeled U -values, describe features: # Panes Frame Type Thermal Break? [Yes [ ] No Comments/Location gi ."f�* -7bw?4 $ (:o 170d S -u 2. U -value: 0.56 For windows without labeled U -values, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location l _I (9i 3. U -value: 0.56 For windows without labeled U -values, describe features: # Panes Frame Type hermal Break? [ ] Yes [ ] No Comments/Locations 77c�o DOORS: 1. U -value: 0.35 Comments/Location cn 2. U -value: 0.54 Comments/Location FLOORS: 1. over Unconditioned Space, R-30 Comments/Location HVAC EQUIPMENT: 1. Boiler, 82.0 AFUE or higher Make and Model Number AIR LEAKAGE: Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. when installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with standard ASTM E 283, with no more than 2.0 cfm (0.944 L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. I VAPOR RETARDER: [ ] I Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. I MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can I be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be I provided. Insulation R -values, glazing U -values, and heating I equipment efficiency must be clearly marked on the building plans or specifications. DUCT INSULATION: [ ] i Ducts shall be insulated per Table 34.4.7.1. DUCT CONSTRUCTION: [ ] i All accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or I joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the I manufacturer's installation instructions. Mesh tape may be I omitted where gaps are less than 1/8 inch. Duct tape is not I permitted."` The HVAC system must provide a means for balancing air and water systems. TEMPERATURE CONTROLS: [ ] I Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. I HVAC EQUIPMENT SIZING: [ 7 I Rated output capacity of the heating/cooling system is I not greater than 125% of the design load as specified I in Sections 780CMR 1310 and ]4.4. I SWIMMING POOLS: [ ] I All heated swimming pools must have an on/off heater switch and I require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. HVAC PIPING INSULATION: [ ] I HVAC piping conveying fluids above 120 F or chilled fluids below 55 F must be insulated to the following levels (in.): PIPE SIZES (in.) I HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4" I Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 Low temperature 120-200 0.5 1.0 1.0 1.5 I Steam condensate any 1.0 1.0 1.5 2.0 I COOLING SYSTEMS: I Chilled water or 40-55 0.5 0.5 0.75 1.0 refrigerant below 40 1.0 1.0 1.5 1.5 I CIRCULATING HOT WATER SYSTEMS: [ ] I Insulate circulating hot water pipes to the following levels (in.): ----NOTES TO FIELD (Building Department Use Only)------------------------- PIPE SIZES (in.) NON -CIRCULATING CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F): RUNOUTS 0-1" 0-1.25" 1.5-2.0" 2.0+" 170-180 0.5 1.0 1.5 2.0 140-160 0.5 0.5 1.0 1.5 100-130 0.5 0.5 0.5 1.0 ----NOTES TO FIELD (Building Department Use Only)------------------------- Project Number' & Title: S 1 ;�,-74-4 Calculations for Square Footage of W alls A A H IAL Floor Plan p 2nd Floor Plan B _ I 11 H3 G F p G C Perimeter I (P1) : A + B + G + Perimeter 2 (P2) = A + 8 + G + p H2 ' 2nd Floor iD+E+F+G 4H I P1 X N1 = Ist Floor wall area (Al) "i P2 X N2 = 2nd Floorperimeter area.(A2) I �6t Floor P3 X 143 = 2nd Floor wall area (A3) _ Al + A2 + A3 = Total wall area Section Work Area Wall calculations Sub Total Window Total Sq. Ft, area to be deducted Exterior poor Total Sq, Ft. area to be deducted Colonial preflln9 Total 5ervlces 'I o Lal = 110 Main 5t., Unit 0204 �� 9 Tewksbury, MA 01816 (918) 851-1330 ]Project Number & Title: S -CLQ Calculations for Floors Floor Plan E `s Length U LXW2Area Area of floor over unconditioned (unheated) space L X W) Total Area of floor over outside air (L X W) Colonial Drafting Services. 110 Main St., Unit 0204 Total otal 7ewkeburg, MA OIB16 ^ (918) 851-1330 Project Number & Title: Calculations for Floors Floor Plan E 1` Length Q) LXW -Area Area of floor over unconditioned (unheated) space (L X W) ` Total Area of floor over outside air (L X W) Colonial DraFting Ser I10 Main Sl., Unit020 8704 Total TewkebuN, MA 01816 (918) 851-1330 i I Project Numb or & Title: Z 1z'rzt4 Calculations for Windows & Doors Table of areae for Double Hung windows Table of areae' for Casement windows APPROXIMATE WIDTH APPROXIMATE WIDTH 110" 2'2" 2'6" 2'8" 2'10' 3'0' 3'2" 3'4" 3'6" 1'5" 1'8" 2'0" 2'4" 2,10" 3b" 3'5' 4'0" 4'9" 6'0" M 4'9 T- 5,1" N 5'5 6.26 " "10.03 7.41 8.54 9.11 9.78 10.25 10.92 11.38 11.96 6.87 8.13 9.38 10.0 10.6111.25 11.88 12.4913.13 7.47 8.85 10.21 10.89 11.67 12.25 12.93 13.60 14.29 8.18 9. 1.0411.78 12.6213.25 14.10 14.7115.58 8,80 10.29 11.8812.67 13.57 14.2515.16 15.82 16.75 9.30 11.02 12.71 13.56 14.39 15.25116 ' 10 16.93 17.79 10.25 11.68 11.7413.54 14.45 15.46 16.25 17.28 18.04 19.09 2-0- 2 4" 0"2'4" p 3'0" 3 3'S" A M 4'0" m 60. r 5'S" 2.83 3.34 4.0 4.66 5.66 6.0 6.83 8.0 9.5 12.0 3,26 3.89 4.66 5.43 6.59 6.99 7.96 9.32 11.07 13.98 4.25 5.01 6.0 6.99 8.49 9.0 10.25 12.0 14.25 18.0 4.84 5.71 6.83 7.96 9.67 10.25 11.68 13.67 16.23 20.5 5.67 6.68 8.0 9.32 11,32 12.0 13.67 16.0 19.0 24.0 7.08 8.35 10.0 11.65 14.15 15.0 17.09 20.0 23.75 30.0 7.67 9.05 10.83 12.62 15.33 16.25 18.5121.67 25.73 32.5 Calculation table for D.H. windows Calculation table for Casement windows Unit size Area of unit X quanfty ■ Sub Total Unit size Area or unit X quanKq - Sub Total ;aiculation table for Glass Doors size Area or unit X quanity " Bub Total Total Calculation table for exterior doors Door size Area or unit X quanity Bub Total Total Calculation table for other glazing Jnit size Area of unit X quanity Sub Total 1/66 1 t/ ,1�7 I 2 1�,, ,r,,l Calculation table for interior doors Door size Area or unit X quanity • Bub Total Colonial ._._. �__ _. _..._.._. _..,.,.- rvlCll alta Vr IrnGflUr UUUfa Drafting Services 2'6" c 16.67 5'0" - 33.35 170 Man St, Unit #204 2'8" = 17.81 6 ' 0 " = 40.00 Tewksbury, MA 01876 3'0" = 20.0 8'0" = 53.36 851-7330 . 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Y (4 q( -00 No. 5 , Date / 1 —3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ P, *-,to. SS c c Building/Frame Permit Fee $ IM4 Foundation Permit Fee $ Other Permit Fee TOTAL Check # J I � 14 3 0 90 3, -11' $ 803, - ZU A� building Inspector 0) CO _O O LO w w � V) O �_ Fw- U � = N � rn Z 0 U W Z W 5 CY 0 N N wLLJ W N II Z W rfi; T s vi O �I NZ w W @C.S r� M < i Cc O p 0 LU m O-:9: Z N II II Z O [� <Q c (n 0 Qf0� PzcaQ xW—> r CN Of LU N Q } W M Z O W U Q < jE WNZ (� w > cn w d O '- ~ � QoU�cr g , O z O p it w LL- I) of��OZ O Z J ��� a Z Q O W Q V Z Z �pQZzO wz�3 V) J (n NO z UUfW� W _ O 0) CO _O O LO w w � V) O �_ Fw- U � = N � rn Z 0 U W Z W 5 CY 0 N N O W N II Z W u O 0 0 } W J x LLJ> 3 C.7 z Of 0 0 Q U Q Date.... TOWN OF NORTH ANDOVER X PERMIT FOR GAS INSTALLATION N�� �) :/ This certifies that ......... has permission for gas installation .... ��O. 4 in the buildings of ... at.... . ............. . .. .. ....... .14 A North Andover, Mass. re ... ..... LAC. no.... ....... .......................... Check # YM 4704 GAS INSPECTOR MASSACHUSETTS UNIFORM APPLICATION (Print a TypeAwa� ) , Mass. Date G� Building FOR// PERMIT TO DO GASFITTING9CO jermit 17 Ile C-- / Owner's Name a d Type of Occupancy, _ R ESI -D N Ti P New ❑ Renovation ❑ Replacement Plans Submitted: Yesp No p Installing Company Nameri Ai:-' 9 T A .:51M MA T A �0 Check one: Certificate Address ire O -DA [ u ry1 A >y i - N[ ❑ Corporation M - 7,H Ue rJ r11 rl 01 k ❑ Partnership Business Telephone /z, 92 — 9 9-7 ( 2-'Firm/Co. Name of Ucensed Plumber or Gas Fitter -f 1) jjE P T A• 5 A M m fq i o INSURANCE COVERAGE: I have a current I}'abiiity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.. Yes i�' No ❑ 1A you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent . Owner❑ Agent C3 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. jTitie 24 /Town O I N T of License: Plumber I-Whifurie of Ue-e—ns-edu or Gas Fitter tter er Ucense- Number ! a3 ) Journeyman �N�EIMEM Installing Company Nameri Ai:-' 9 T A .:51M MA T A �0 Check one: Certificate Address ire O -DA [ u ry1 A >y i - N[ ❑ Corporation M - 7,H Ue rJ r11 rl 01 k ❑ Partnership Business Telephone /z, 92 — 9 9-7 ( 2-'Firm/Co. Name of Ucensed Plumber or Gas Fitter -f 1) jjE P T A• 5 A M m fq i o INSURANCE COVERAGE: I have a current I}'abiiity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.. Yes i�' No ❑ 1A you have checked yes, please indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent . Owner❑ Agent C3 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the pe ed for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. jTitie 24 /Town O I N T of License: Plumber I-Whifurie of Ue-e—ns-edu or Gas Fitter tter er Ucense- Number ! a3 ) Journeyman z 0 P 0 w U) w cc 0 0 of z 0 I— IL) w z Z LL. A 0 0 w L6 L6 0 0 0 LL 0 IL CL ut w 16 of z 0 I— IL) w z Z LL. z I- I- s w A 96 0) IL 0 0 z c w 21 0 A IL