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Miscellaneous - 488 PLEASANT STREET 4/30/2018
FILE -17- Date.................................. 6 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING AcwU Thiscertifies that .................................................../........................................... has permission to perform ....k4l, .......... ne.,-�... ............... ..... . ....... ... ....... . ......... wiring in the building of...... ...1... . . ......................................... at..//................................................ North AMadove, w. Lam Fee..,r .......... Lic.No.............. .... ........ . ............. E CAL INSPECTOR Check # 059�2 p� 4 //�� DD/' / Official Use Only (�o►nmonureaUh o1cc�al9achu�et� Y _ Apartment ol.}ire�ewicee_ _ -- Permit No. /® – p BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked "V [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 A FO TON) Date: City or Town of: U te.. To the Inspector of Wires: By this application the undersigne gives notice of Iiis or her int ntion to_perform the electrical work described below. Location(Street&Number) Owner or Tenant gre clrbr— Telephone N .COO- Owner's Address ,,s s7 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: til f Completion of the.following 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- ❑ 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 No.of Detection and TotInitiatin Devices No.of Ranges No.of Air Cond. ons No.of Alerting Devices No.of Waste Disposers Heat Pump Number.._Tons. KW No.of Self-Contained Totals: 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 E uivalent No.of WaterNo.KW No.of No.of Data Wiring: Signs 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 El ctric l Work: ct QW d�U (When required by municipal policy.) Work to Start: ///7//.2--inspections to be requested in accordance with MEC Rule 10,and upon completion. r'^ INSURANCE C VE GE: 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 K BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee:h� , / Signature C.NO: 26402, (If applicable,enter "e,empt"in the e 'tensber lin. . ����� Bus.Tel.No p Address: Alt.Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires PXekhent 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. S �/ ,-A? z The Commonwealth of Massachusetts Department of Industrial Accidents - - - -- -- - - — Offtce-of-In vestigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer?Chec the appropriate box: Type of project(required): 1.El am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2:K1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10, Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]f employees. [No workers' 13.0 Other comp.insurance required.] *An applicant that y pp checks box#1 must also fill out the section below showing their workers'compensation policy information. f 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 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and the pains and enalt' o per'ury tltat the information provided above is true d correct. Si nature: /J� / 1 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#: Dat . ?!/?!/Z. ... ... 1 °f H0 oT e,ti° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9 SSACMUSEt 1 This certifies that . . . . "ae Ze� . . . . . . has permission for gas installation . . . �-s . .!' �. . . . ." in the buildings of at . . �8 ! �4s� . . . . . . ., North Andover, Mass. Fee.�0 4o. Lic. No.,X4R51-4 GAS INSPECTOR Check# D .� p ': 0089 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:. Aifidk INa UW MA. Date: 3 f 2 Permit# Building Location: 7�� j���q Scth �t Owners Name: Type of Occupancy: Commercial ❑ Educational❑ Industrial❑ Institutional❑ Residential New: 9 Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES-- - - - - - - - - - - co Lu Lu co co Q W f•- � w o: 0 � z FIM =- 0 0 �_ } z to 0 2 w W 0z z O � F � w lX0 Q M � W Z m 0 a n0 LU . I— W W LU W Q w LL, W z to = CO - W F O Li Z W W Z O J I- h O Z - O LL H = W W W O W a it w W . m W O z 0 m t > z I'- _ V 17 LL 0 0 = T < 0 M > > > 0 SUB BSMT. BASEMENT 1FLOOR 2FLOOR 3 K DFLOOR 4 FLOOR 5 FLOOR 6 FLOOR ' 7 FLOOR 81H FLOOR / c y Check One Only Certificate# Installing Company Name:_ 2• Yc-2 I ;D/14 4iA5 ❑Corporation 32- Fax: Address- /21 )5;r4 HIII G City/Town: ��el/ State: r" � Business Tel: � � ��os ys El Partnership ❑Firm/Company Name of Licensed Plumber/Gas Fitter: ?1-12-1 2,5—J grr` ' L�a� 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 ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner El Agent By checking this box❑;I hereby certify that all of the details and information I 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: ❑Plumber Title ❑Gas Fitter ur o Licensed r/Gas Fitter ❑Master City/Town 2kourneyman License Number: /`x(32 12 5`"v-r APPROVED OFFICE USNLY ElLP Installer - ti • .� The Commonwealth ofmassachusetts Department of Industrial Accidents Office of Invesfigations ..600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/OrganizationAndividual): Address: —— — City/State/Zip: Phone M Are you an employer?Check the appropriate boxc [2. ❑ T am a employer with 4. ❑ I am a general contractor and Ir7. n f project(required):employees(full and/or part-time).*' have hired the sub-contractors New construction❑ I am a sole proprietor or partner- listed on the attached sheet.l Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. El We are a corporation and its 9' El Building addition required.) officers have exercised their 10.❑Electrical repairs or additions 3.E1.1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no insurance required.)t12-ElRoof repairs employees. [No workers' comp.insurance required.] 13.❑Other rainy EpphCant th Ft checalks box 4"t]yryL,gt B�Sf�fil?e:tt fhe sectio- el chn�irinrr rl.e s *1 below .Yb..._u•wore e v comPe•sation 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 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.Lie.#: 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 may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certify under the pains and penalties ofperimy that the information provided above is true and correct Signature: 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 Z.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.PIumbin6Inspector 6.Other Contact Person: Phone#: I 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 unrtil 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 maybe 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 is behng requestn44,not 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 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 homeowner or.citizen is obtaining a license or permit not related to any business.or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would'like to thank you in advance f6r 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 Department of Industrial Accidents Office ofIurestigations 600 Washington Street Boston,MA 0211.1 Tel. #617-727-4900 ext 406 or 1-8.77M. ASSAFE Fax#6.17-727-7'749 Revised 5-26-05 v, w.Fnass..gov/dia O 1d=umµ{ CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 586 (4/12/2005) Date: May 10, 2006 THIS CERTIFIES THAT THE BUILDING LOCATED ON 488 Pleasant Street MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Gerald Brecher&Louise Borke 488 Pleasant Street North Andover MA 01845 Buildi g Inspector II . .v N® ' ToVM Of Andover0 t SOS to ����' ►( ---- .� dover, Mass. y'� •� f�4� Y O LA E > cOC HICNE WICK V �d ADRATED PPS` iC5 S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System • BUILDING INSPECTOR THIS CERTIFIES THAT0 �► y n has permission to erect.......... ....... buildings on �� ft '................. ..................... Rough ; /', 2�, 01 s, st��� to be occupied as ,,l�,iJ�c p ............................. ...............................V... 1....r... .y .. ............ �Caf provided that the person accepting this permit shall in every respect conform to the terms of the ( plication on file in final this office, and to the provisions of the Codes and By-laws relating to the In pection, Alteration and Construction of �'/G Buildings in the Town of North Andover. UMBING INSPEETOR VIOLATION of the Zoning or Building Regulations Voids this Permlt. 0 S os PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR *1q1PP9qW..Wn— N , T S be .. ....... ..4j -j)460�. .. .. Service .. . ...... .............SPECTOR ';0"< Occupancy Permit Required to Occupy Building GAS INSPECTOR_ Display in a Conspicuous Place on the Pr — �u P Y p emeses Do Not Remove COX� L-0 No Lathing or Dry Wall To. Be Done FIRE DEPAR Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. I r 0� R toc tnt was«� sSACHUS APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit# ADDRESS/LOCATION OF PROPERTY : �_ Q��Cwy/V ,S- e2:1yc,)a a2z� 0_ve%�5 DATE REQUESTED FILED/READY FOR INSPECTION— CLOSING DATE ON PROPERTY: -Z4? -6& 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 DOES NOT MEET ALL APPLICABLE CODES. SIGNED ROUTING CONSERVATION F-1 PLANNING 1 DPW -WATER METER F7 NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW �f�, �f� 5 -�- 0� VSicffiature File: OC form revised 2006 488 Pleasant Street North Andover, MA 01845 May 10, 2006 Mr. Gerald Brown Building Inspector Town of North Andover Route 125 North Andover, Ma 01845 Dear Mr. Brown, Please find following a punch list of items that must be completed on our new house at 488 Pleasant Street as of today: 1) grade front entrance (a temporary step will be installed until the grading is completed) 2) install chimney masonry 3) complete landscaping 4) install asphalt covering of upper and lower driveways 5) finish hardwood flooring 6) install final railing around stairs (a temporary railing is in place for safety currently) 7) complete caps on outside deck railing 8) put fridge in kitchen 9) install handles on inside doors and cabinets 10)install front door knob and lock 11)install fireplace mantle in living room I understand that you will come back to inspect all of these items upon completion, but that you agree to issue the Occupancy Permit in the meantime to enable our mortgage closing to go forward next week. Thank you. Sincerely Louise 1. Borke y � OorrrH � 0 Sr4�o Fa'e Q©L 0 GO[MILXt Wt[N V q°Arlo FiUS�� APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit# a9 ADDRESS/LOCATION OF PROPERTY : DATE REQUESTED FILED/READY FOR INSPECTION_ LO(, 5/q, r«�� CLOSING DATE ON PROPERTY: `ljD 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 DOES NOT MEET ALL APPLICABLE CODES. SIGNED ROUTING CONSERVATION F1 PLANNING F-1 DPW -WATER METER Fv�i NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPWj4rld-ft � �11�eA\�-- Signature File: OC form revised 2006 \ J ,• ��.� .� ®��/G Location No. S�� Date _Z -4 ;A < MaRTM TOWN OF NORTH ANDOVER " Certificate of Occupancy $ ° s"ANUS t� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ Check # 181 '1 9 /;! Building Inspector � r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING HT1 BUILDING PERMIT NUMBER: DATE ISSUED: Z-0 SIGNATURE: Building Commissioner/Inspe6tor of Buildings Date Z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Distrid Proposed Use Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided v 1.7 Water Supply UG.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Sita Disposal System ❑ SECTION 2-PROPERTY OWNERSIMP/AUTHORIZED AGENT rn 2.1 Owner of Record G©m PAss Name(Print) Address for Service Sig natu one 2.2 Owner of Record: 1 O Nana:Print Address for Service: Z rn Si na'. a Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable. Licensed Construction Supervisor: Q License Number mn Address ic Expiration Date Signature Telephone r 3.2 Registered Home Improvement Contractor Not Applicable ❑ 0 Company Name rn Registration Number Address r Z Expiration Date P1 Signature Telephone �I 'I r 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 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description p n of Proposed Work: i� SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be— gq` �F g Completed by permit applicant s �� i 1. Building p O o C) (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of /t� Construction q/ O� 3 Plumbing Building Permit fee(8)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a ON OWNER AUTHORIZATION TO BE OWNERS AGENT OR CONTRACTOR APPLIES OR COMPLETED UILDING WHEN I' as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION property ,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 y+r Z_0 s- Print SiNature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3 SPAN 7771 DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS DIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING R MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I 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 SECTION APPLICANT c TI ( 2. M9— 401 — 33 (9 PHONE LOCATION: Assessor's Map Number!_2,."_ PARCEL—e:L�i"� SUBDIVISION f, LOT(S) STREET e6 ;-cLd �"I' <3( ST. NUMBER OFFICIAL USE ONLY I IQND OF TOG NTS: CONSERVATION ADMINISTRATOR DATE APPROVED ZIL DATE REJECTED, , COMMENTS TOWN P ER DATE APPROVED DATE REJECTED COMMENTS ,"I' FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS7 05 DRIVEWA I ERMIT - FIRE DEPARTMENT 2 RECEIVED BY BUILDING INSPECTOR DATE RevlsW 9197 Jm I f } 2002 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. 7 r�-- .� Application by the undersigned is hereby made to connect with the town sewer main in __ /L`'�;5��y V Street, subject to the rules and regulations of the Division of Public Works. F, The premises are known as No. j`�c hh Street or subdivision lot no. A m?"O" Owner Address I Contractor Address Applica s Signature PERMIT TO CONNECT WITH SEWER MAIN The Division of Public Works hereby grants permission to C— �1w" 15i�;-5' �r9 C�<'�!, (e -5 to make a connection with the sewer main at �Y'C� �a Street. subject to the rules and regulations of the Division of Public Works.. Division)of Public Works By Inspected by Date See back for rules and regulations 1 r 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 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 1 373 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. f g--- 7 Application by the undersigned is hereby made to connect with the town water main in 4-'/'eCf: "vim ' Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. 1 Street or subdivision lot no. � /7- ,5[,q -5J-j C 7 > Owner � � � f��� ..� Address Contractor Address / Applicant'&-Tignature f r� �r PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to to make a connection with the water main at Street subject to the rules and regulations of the Division of Public Works. Bo rd o Publi Works By Inspected by Date See back for rules and regulations NosrH TOWN OF NORTH ANDOVER 0 _ DIVISION OF PUBLIC WORKS 2.6'.r i ` Op 384 OSGOOD STREET NORTH ANDOVER,MASSACHUSETTS 01845 S' E Telephone(978)685-0950 Fax(978)688-9573 CHU5 q Sa , DRIVEWAY PERMIT June 1, 1999,Revised 06-01-02 (Please Print) DATE: 3 -17- 04 STREET &NUMBER: ��} / �t�G r/ILOT NUMBER: CONTRACTOR: TEL: ADDRESS: FAX: OWNER: TEL: ADDRESS: PROPOSED PLAN OF DRIVEWAY ATTACHED: PROPOSED SITE DISTANCE: DIG SAFE NUMBER: SITE INSPECTION IS REQUIRED BEFOREO�IJRS UFRNOTIFICATACE IS INSTALLED O OF COMPLETION.AND A FINAL INSPECTION WILL BE MADE WITHIN 48 INITIAL INSPECTION DATE: BY: FINAL INSPECTION DATE: BY: FAILURE TO COMPLY WITH THESE CONDITIONS OR TO OBTAIN REQUIRED INSPECTIONS AND THIS PERMIT DOES NOT RELIEVE THE APPLICANT APPROVALS VOIDS THIS PERMIT. APPROVAL OF FROM MEETING ALL OF THE REQU FIREMENT S OPENING PERMIT IS REQUIRED PERFORMED WITH E STREET YEMEN ET Attachments made a part of this permit: Form U & Driveway Application Requirements Sketch"A"Proposed Driveway Plan, dated 06-01-99 Sketch"B"Typical Drivewa tail at 06.01-99 T SIGNATURE: DATE. 3, APPLICANT DATE: J 22 DIVISION OF PUBLIC WORKS SIGNATURE: 7 17�1� i4yni U&Driveway Applications Rev 6-7-02 s GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVERBU ILDING 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 informationa equested w. �oi4� Permit Applicant Property address Map/Parcel 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 of the 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 of this 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 met 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 to a minimum 40%permanent reduction in density(buildable lots)below the density permitted under zoning and feasible giver the environmental conditions of the tract,with the surplus land equal to at least ten 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 ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 and shall receive a onetime exemption from the Planned Growth Rate and Development Scheduling provisions for thepurpose 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 ASSIST THE 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 WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR NOT S GR S FOR RnUB�Y THE BUILDIN DEPARTMENT TO ISSUE A BUILDING PERMIT. APPLICANTS SIGNATURE DATE THIS FORM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION i ' AORT11 TOWN OF NORTH ANDOVER OFFICE OF p BUILDING DEPARTMENT x 400 Osgood Street North Andover,Massachusetts 01845 ?SSACHUSe1 D.Robert Nicetta, Telephone(978)688-95454 Building Commissioner Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION Please print DATE: JOB LOCATION: �L - �S /`U/ S7- 47o Number Street Address Map/Lot HOMEOWNER LO v o — O7— 33 Name Home Phone Work Phone PRESENT MAILING ADDRESS Z � r /f�S/ &01� 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 an individual 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 HOARD OFAATEALS 688-9541 CONS IT VATI ON 699-9530 IIFAI;FII689-9540 PLANNING 688-9535 BRECHER/BORKE RESIDENCE Pleasant Street North Andover Energy Compliance Certificate Calculations and Drawings Prepared by ADC/Architectural Design.Concepts, Inc. 200 Sutton Street North Andover, MA 01845 978-686-2112 ADC CONCEPTSARCHITECTURAL Permit Number REScheck Compliance Certificate Checked By/Date 2000 IECC REScheck Soffware Version 3.6 Release 2 Data filename: C:\Program Files\Check\REScheck\Brecher-Borke2.rck PROJECT TITLE: Brecher/Borke Residence CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: Single Family WINDOW / WALL RATIO: 0.28 DATE: 03/28/05 DATE OF PLANS: February 2005 PROJECT DESCRIPTION: Custom Residence on Pleasant Street DESIGNER/CONTRACTOR: ADC architects ,a COMPLIANCE: Passes Maximum UA= 736 Your Home UA = 723 1.8%Better Than Code(UA) Gross Glazing Area or Cavity Cont. or Door Perimeter R-Value R-Value U-Factor UA Ceiling 1: Cathedral Ceiling (no attic) 1196 30.0 0.0 41 Ceiling 2: Flat Ceiling or Scissor Truss 1292 30.0 30.0 22 ` Wall 1: Wood Frame, 16" o.c. 610 19.0 0.0 31 Window 1: Wood Frame:Double Pane with Low-E 89 0.320 28 Wall 2: Wood Frame, 16" o.c. 610 30.0 0.0 18 Window 15: Wood Frame:Double Pane with Low-E 26 0.320 8 Window 16: Wood Frame:Double Pane with Low-E 20 0.320 6 Window 2: Wood Frame:Double Pane with Low-E 44 0.320 14 Window 3: Wood Frame:Double Pane with Low-E 24 0.320 8 Door 5: Glass 78 0.320 25 Door 1: Solid 47 0.320 15 Wall 3: Wood Frame, 16" o.c. 959 19.0 0.0 46 Window 6: Wood Frame:Double Pane with Low-E 93 0.320 30 Window 7: Wood Frame:Double Pane with Low-E 15 0.320 5 Window 8: Wood Frame:Double Pane with Low-E 50 0.320 16 Window 9: Wood Frame:Double Pane with Low-E 20 0.320 6 Door 2: Solid 21 0.320 7 Wall 4: Wood Frame, 16" o.c. 554 19.0 0.0 30 Window 10: Wood Frame:Double Pane with Low-E 15 0.320 5 Window 11: Wood Frame:Double Pane with Low-E 37 0.320 12 Wall 5: Wood Frame, 16" o.c. 1181 19.0 0.0 39 Window 13: Wood Frame:Double Pane with Low-E 73 0.320 23 Window 14: Wood Frame:Double Pane with Low-E 28 0.320 9 Door 3: Glass 233 0.320 75 Door 4: Glass 201 0.320 64 Basement Wall 1: Solid Concrete or Masonry 419 11.0 4.0 18 Wall height: 9.0' Depth below grade: 8.0' Insulation depth: 9.0' Window 4: Wood Frame:Double Pane with Low-E 6 0.320 2 Window 5: Wood Frame:Double Pane with Low-E 45 0.320 14 Basement Wall 2: Solid Concrete or Masonry 403 11.0 2.5 21 Wall height: 9.0' Depth below grade: 8.0' Insulation depth: 9.0' Window 12: Wood Frame:Double Pane with Low-E 7 0.320 2 Basement Wall 3: Solid Concrete or Masonry 120 11.0 4.0 6 Wall height: 9.0' Depth below grade: 8.0' Insulation depth: 9.0' Floor 1: All-Wood Joist/T russ:Over Unconditioned Space 634 30.0 0.0 21 Floor 2: Slab-On-Grade:Heated 82 10.0 56 Insulation depth: 6.0' Boiler l: Other(Except Gas-Fired Steam), 85 AFUE Air Conditioner 1: Electric Central Air, 10 SEER COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit applicati4'j Tlfe,proposed building has been designed to meet the 2000 IECC requirements in RES check Version 3.6 Release 2 (formerly MECcheck) and to comply with the mandatory regffilirents listed in the REScheck Inspection Checklist. 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LA. e. iiii ui ILL 10011-5:11N� ..L.. ---------- -------- ------- -------- TT ------- ------------ -------7------------- :-------- ------------ o ul JAZ 73 7-7 ?-3 2 a> M�bo U-) Z� S l @ 77,7 SCALE: 2 3 (e� / W DRANGNUMBER! A3.3 C L� - I 5o o Norte JF ------------------j C LLr 2 zAR:IIOY]ODI -------------- ------------------------ ---------- --------------------- --- ---- --- --- F- Ls 16z z SCALE:W- DRAWNG NUM A2.2 o*zv 737v3s A 0 0 CD gi z ---—----------- > > - ----------------------------------- >cc ------------------ ---- ------------------- ----------- ----------------------------- ----- ------------ ------------------- ------------------ 71 ----------------------------------- --------- ---- -------------------------------------------------- ------------------------------------------ ---------------------- ------------------------ ---------------------------------- _____--____________________ - -------------------------------------- ---------------------------------- ol I------------------------------------------ L------------------------------- ---------------------------- ----------------------- --------- -- -------------- -------- -- ---------- ------------------ ----------- ----------------- ----- -------- -------------------- ------------------- ----------- ---------- All 7�7�L_ ---------------------- ------------------------------ ------- ------------ - ------------- El RES check Inspection Checklist 2000 IECC REScheck Soffware Version 3.6 Release 2 DATE: 03/28/05 PROJECT TITLE: Brecher/Borke Residence Bldg. Dept. Use I Ceilings: [ ] I 1. Ceiling 1: Cathedral Ceiling (no attic), R-30.0 cavity insulation Comments: [ ] I 2. Ceiling 2: Flat Ceiling or Scissor Truss, R-30.0 cavity + R-30.0 continuous insulation Comments: I Above-Grade Walls: [ ] I 1. Wall 1: Wood Frame, 16" o.c., R-19.0 cavity insulation Comments: [ ] I 2. Wall 2: Wood Frame, 16" o.c., R-30.0 cavity insulation Comments: [ ] I 3. Wall 3: Wood Frame, 16" o.c., R-19.0 cavity insulation Comments: [ ] I 4. Wall 4: Wood Frame, 16" o.c., R-19.0 cavity insulation Comments: [ ] I 5. Wall 5: Wood Frame, 16" o.c., R-19.0 cavity insulation Comments: I Basement Walls: [ ] I 1. Basement Wall 1: Solid Concrete or Masonry, 9.0' ht/8.0' bg/9.0' insul, R-11.0 cavity+ R-4.0 continuous insulation Comments: Exterior insulation must have a rigid, opaque, weather-resistant protective covering that covers the exposed (above-grade) insulation and extends at least 6 in. below grade. [ ] I 2. Basement Wall 2: Solid Concrete or Masonry, 9.0' ht/8.0' bg/9.0' insul, R-11.0 cavity + R-2.5 continuous insulation Comments: Exterior insulation must have a rigid, opaque, weather-resistant protective covering that covers the exposed (above-grade) insulation and extends at least 6 in. below grade. [ ] 3. Basement Wall 3: Solid Concrete or Masonry, 9.0' ht/8.0' bg/9.0' insul, R-11.0 cavity + R-4.0 continuous insulation Comments: Exterior insulation must have a rigid, opaque, weather-resistant protective covering that covers the exposed (above-grade)insulation and extends at least 6 in. below grade. Windows: [ ] 1. Window 1: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ]No Comments: [ ] 2. Window 15: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors,-describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 3. Window 16: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 4. Window 2: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 5. Window 3: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 6. Window 6: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 7. Window 7: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: #Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 8. Window 8: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 9. Window 9: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ]No Comments: [ ] 10. Window 10: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 11. Window 11: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 12. Window 13: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 13. Window 14: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: #Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 14. Window 4: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 15. Window 5: Wood Framc:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: #Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: [ ] 16. Window 12: Wood Frame:Double Pane with Low-E, U-factor: 0.320 For windows without labeled U-factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: Doors: [ ] 1. Door 5: Glass, U-tactor: 0.320 Comments: [ ] 2. Door 1: Solid, U-factor: 0.320 Comments: [ ] 3. Door 2: Solid, U-factor: 0.320 Comments: [ ] 4. Door 3: Glass, U-tactor: 0.320 Comments: [ ] 5. Door 4: Glass, U-factor: 0.320 Comments: Floors: [ ] 1. Floor 1: All-Wood Joist/T russ:Over Unconditioned Space, R-30.0 cavity insulation Comments: [ ] 2. Floor 2: Slab-On-Grade:Heated, 6.0' insulation depth, R-10.0 continuous insulation Comments: Slab insulation to extend down from the top of the slab to at least 6.0 ff. OR down to at least the bottom of the slab then horizontally for a total distance of 6.0 1. Exterior insulation must have a rigid, opaque, weather-resistant protective covering that covers the exposed (above-grade) insulation and extends at least 6 in. below grade. Heating and Cooling Equipment: [ ] 1. Boiler 1: Other(Except Gas-Fired Steam), 85 AFUE or higher Make and Model Number [ ] 2. Air Conditioner 1: Electric Central Air, 10 SEER 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. [ ] Recessed lights must be 1)Type IC rated, or 2) installed inside an appropriate air-tight assembly with a 0.5" clearance from combustible materials. If non-1C rated, the fixture must be installed with a 3" clearance from insulation. Vapor Retarder: [ ] Required on the warm-in-winter side of all non-vented framed ceilings, walls, and floors. Materials Identification: [ ] Materials and equipment must be installed in accordance with the manufacturer's installation instructions. [ ] Materials and equipment must be identified so that compliance can be determined. [ ] Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. [ ] Insulation R-values, glazing U-factors, and heating equipment efficiency must be clearly marked on the building plans or specifications. Duct Insulation: [ ] Ducts in unconditioned spaces must be insulated to R-5. Ducts outside the building must be insulated to R-6.5. Duct Construction: [ ] I All joints, seams, and connections must be securely fastened with welds, gaskets, mastics (adhesives), mastic-plus-embedded-fabric, or tapes. Tapes and mastics must be rated UL 181A or UL 181B. Exception: Continuously welded and locking-type longitudinal joints and seams on ducts operating at less than 2 in. w.g. (500 Pa). [ J The HVAC system must provide a means for balancing air and water systems. Temperature Controls: [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut offthe heating and/or cooling input to each zone or floor shall be provided. Service Water Heating: [ J Water heaters with vertical pipe risers must have a heat trap on both the inlet and outlet unless the water heater has an integral heat trap or is part of circulating system. [ ] Insulate circulating hot water pipes to the levels in Table 1. Circulating Hot Water Systems: [ ] Insulate circulating hot water pipes to the levels in Table 1. Swimming Pools: [ ] All heated swimming pools must have an on/offheater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. Heating and Cooling Piping Insulation: [ ] HVAC piping conveying fluids above 105 °F,pr chilled fluids below 55 °F must be insulated to the , N E"� G .� N Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes. Insulation Thickness in Inches by Pine Sizes Heated Water Non-Circulating Runouts Circulating Mains and Runouts Temperature(Fl Up to 1„ Un to 1.25" 1.5" to 2.0" Over 2„ 170-180 0.5 1.0 1.5 2.0 140-169 0.5 0.5 1.0 1.5 100-139 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes. Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Ran e F 2" Runouts 1" and Less 1.25" to 2" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate(for fired water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant, 40-55 0.5 0.5 0.75 1.0 and Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD (Building Department Use Only) A' .Building Value Calculation - for Property at..... LOT# Room Length Width Sq.Ft. Cost per Sq.Ft. Total Cost Kitchen 24 16 384.00 125 $ 48,000.00 Brkfstnook - 125 $ - Dining Room - 125 $ - Family Room - 125 $ - study/office - 125 $ - Living room 24 18 432.00 125 $ 54,000.00 Garage 26 24 624.00 125 $ 78,000.00 Entry 14 18 252.00 125 $ 31,500.00 2nd floor foyer/sitting - 125 $ - Great room - 125 $ - mudroom 20 14 280.00 125 $ 35,000.00 Walkin closet - 125 $ - Basement Finished - 125 $ - Media room 15 28 420.00 125 $ 52,500.00 sunroom - 125 $ - laundry - 125 $ - Bedroom 1 32 18 576.00 125 $ 72,000.00 Bedroom.2 32 18 576.00 125 $ 72,000.00 Bedroom 3 28 15 420.00 125 $ 52,500.00 Bedroom 4 24 15 360.00 125 $ 45,000.00 Media room 125 $ - Bathroom - 125 $ 1/2 Bath - 125 $ - Bathroom 2 - 125 $ - Bathroom - 125 $ - Deck 430.00 10 $ 4,300.00 Balcony - 125 - Volpe Center Enter construction cost for fee cal [7$- 544 .nn ��� v0 Construction Cost Building Fee $ 5,448.00 Plumbing Fee $ 817.20 Gas Fee $ 75.00 Electrical Fee $ 817.20 Total fees collected $ 7,157.40 488 Pleasant Street � j5 � NORTH Town of t �r. 4Andover No. s,S4 -7W W " dover, Mass., 'y / 'e> COCHICKEWICK V ORATED P41' �y S BOARD OF HEALTH Food/Kitchen PERMIT T Septic System Owt if BUILDING INSPECTOR THIS CERTIFIES THAT....... -0rAA�,........,��.d..... M &3 A� # ndation has permission to erect............. ................. ........ buildings on ..... ....................... Rom, .00 to be occupied as. ...................�............... ............1............... 1.. V44.8��`..S S. a �..�............ himney provided that the person accepting this permd shall in every respect conform to the terms of the plication on file in this office, and to the provisions of the Codes and By-Laws relating to the In pection, Alteration and Construction of Final 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 CONSTRU N T S ELECTRICAL INSPECTOR � Rough .. .. .......... .... .. Service B DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove F nal h No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. ADC ARCHITECTURAL D E S I G N C O N C E P T S I N C O R P O R A T E D 200 SUTTON STREET NO. ANDOVER, MA 01845 TELEPHONE(978)686-2112 FACSIMILE (978) 686-4344 www.ADCarchitects.com December 28,2005 Mr. Gerald Brown,Bldg.Commissioner Town of North Andover 400 Osgood Street . North Andover,MA 01845 Re: Brecher/Borke Residence Pleasant Street,North Andover Dear Mr. Osgood, This letter is in answer to your request regarding the egress at the above residence. I have considered this residence a raised ranch style in accordance with Section 3603.10.1 "Exception: In split level and raised ranch style layouts, the two separate exit doors required by 780 CMR 3603.10.1 are permitted to be located on different levels." If you have any questions please feel free to call me at your convenience. My b st e s 1 DA QGE E.ggri �O George E azoyk A o �' No.a l DFORD v ASS. y CC: Mr.Jerry Brecher F Nr 7 New Hampshire Office 100 MAIN ST.,SUITE 10 • NASHUA, NH 03060 Telephone 603-880-8555 - F-acsimi le 603-880-3335 Date.&-a. ` ... MORTM pf ,.ao ,e,ti0 0 TOWN OF NORTH ANDOVER two + PERMIT FOR GAS INSTALLATION + a ..ao•�• 4y �9SSACHUSEt This certifies that . . : .% !1?-w-:. . ? . . . . . . . . . . . . . . . . . . has permission for gas installation ._. . . . . . . . . . . . . . . f! in the buildings-of .'r �^�'. . . . . . .�`... .. . . . . . . . . . . . . . . . . at . i.P North Andover, Mass. Fee. X12,. . Lic. No.. .// ql. ! . . . . . . . . . . GAS INS�EC�OR Check# /tom' 5341 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO CASFITTiNG (P nt or ry�?,e�) V , _( � r d DW-r Mass. Date 19 Permit# Building Location U Pff-aS0A fi�tUwners Name Type of Qccupancy New � Renovation Q Replacement p Plans Submitted: Yes© No D m s � z s sir 2 Z 0 a Q yr r y 4 O a a I 4 ¢ Z- 't d t < O O tit -C p YZ- s C 'Z O s7 S tE. 9 Q ..s U = > c3 a 1• Q sue-55MT. I LJ BASEMENT 1ST FLOOR 2x0 FLOOR 4 3110 FLOOR _ ATH FLOOR 5TH FLOOR 5TH FLOOR TTHFLOOR $TkFLGOR Instatling Company Igame 9S lNG i VEFMC46*1 Check one: Certificate Address —7 14 8PDA0W)11 Corporation s C e IL-S'�-AO 3, t S Ca ❑. Partnership Business Telephone (GLI) 9604 -22-2 1 0 Firm/Co. Name of Licensed Plumber or Gas Fitter -"00eQ K E Mi� ------ INSURANCE COVERAGE: I have a current iabil'ity Insurance policy or its substantial equidalent which rneets the requirements of MGL Ch. 142. Yes iNK No 0 If you have c ecfted yes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy Cather type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws. and that my signature on this perms application wanes this requirement- Check one: Owner0 Agent 0 Signature of Owner or Miners Agent I hereby cortii`y that all of the details acid information I have submitted for entered)- above application are true and accurate to the best of cry knowledge aW that all plumbing work and irstallations performed under the pe r issued for this ap i Qe:n comp vaith all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of th ,.iiia 3 By T of License, plumber g W Licensedi�'umber ar Gas fit:er Title WGasrtter /t C— Q Master license Number {9 J f tatyfTown Li Joumeyman A,PPAET.rID is I U r. NL ' Location F. No Date TOWN OF NORTH ANDOVER 0 Certificate of Occupancy $ Building/Frame Permit Fee $ SACHUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 83Z8 Building Inspector SUBJECT PROPERTY: ZONING DISTRICT R3 LEGAL REFERENCES: FRAN OF M,4 I s DATE: JUNE 21, 2005 SCOTT L. GILES MAP 95,PARCEL 24 MIN AREA=25,000sf ASSESSOR MAP 95, PARCEL 24 FRA S REVISIONS: FRANK S. GILES -- 488 PLEASANT ST MAX HEIGHT=35 ft PLAN#2631 N.E.R.D. o i S SURVEYING COMPASS PROPERTIES, INC TRUSTEE MIN. FRONTAGE= 125 ft BK. 5943, PG. 101 v SCALE: V= 20' 50 DEERMEADOW ROAD P O BOX 474 MIN. FRONT SETBACK=30 ft ,09 , o� 0, NORTH ANDOVER,MA 01845 NORTH ANDOVER, MA 01845 MIN. SIDE SETBACK=20 ft N® sLc -� ' 20 40 TEL: (978) 683-2645 BK. 5943, PG. 101 MIN. REAR SETBACK=30 ft 2 ;'2005 FrankGilesSurvey@comcast.net PLAN OF LAND LOCATION eA5"J'0+ 488 PLEASANT STREET 55 U�� z f��- NORTH ANDOVER, MA PREPARED FOR COMPASS PROPERTIES INC. Stevens Pond I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING ELEVATION WATER 105.92 BY LAWS OF NORTH ANDOVER, MA. AT THE TIME OF CONSTRUCTION. FEBRUARY 27,2001 \�SF �NT THE OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON-CONFORMITY WHEN CONSTRUCTED. MAP 95-PARCEL 2200 KIMBERLY &JONATHAN p S b~ \ rF92 THOMPSON, 430 PLEASANT STREET 20.5' NORTH ANDOVER,MATjO�r MAP 95 - PARCEL 24 LOT 6 �o Area=26,880 sf \ \ \4301+_ PT--v \ g0� STREET \ 4 5952 Date....... ....... .... .... ...... NORTH 4, TOWN OF NORTH ANDOVER PERMIT FOR WIRING 3 US - This certifies that ........... ........... ......... .. ..................................... .... ... 7— has permission to perform ........... �-F—Ic.................................. wiring in the building of..... .....� ?�T-f'r�•••.•••••..••.•••.• 4P �Ie40- at............IrF,— ...................I�r.!!�......................... North Andover,Mass. A Fee�:-?. .. Lic.No?!��3.......12 ?--A........... ELECTRICAL INSPZ R�-/ Check # IIMLummulvVVE.Ai inUrL3 �•• �� DEPARTAIENfOFPUBUCSAMY Permit No. BOARDOFFMPREVEMONROGUTAHONSM7C1&]2iW Occupancy&Fees Checked APPLICATION FOR 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) Dat 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) k, J1 Owner or Tenant �1'L Owner's Address Is this permit in conjunctioVwi,,a building rTm Yes� No [a (Check Appropriate Box) Utili Authoriz�a�U?onC). Purpose of Building � Utility Existing Service �C11 6ps_ volts Overheadderground D No.of Meters New Service PSL / t- Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work 77 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round El ground rl No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No,of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal r"n Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP i OTHER hiauanoeCa�erdge.Plasuantmdetegyuerrlatls� Laws IhaNeacuaentLiabil[yk6MX�e irtthitiftgccnvw • (bverageofitsat"Megttivalat YES + ,. NO Ihavesibrri ledvalidpioofof iotheOffm YES ff}vulu drd®d plraseindrateth Wcf chec1INSURANCE BOND GIHM a (1'le�esptxxsiY) �' D BtpitnbalDa� Rstir *dVatledE1X CdWodc$ wodcaosatt klV0cfiMDa1eReiqueSWd Rough FxW SigriedurlderTr,Ph>altiesafperjtry L) A s.���, 1 n , FIRMNAME (� t_:UC Lioaw% 0. Iicerisae (� 1� /� �1 u Sigtiatiae Lioai9eNo Busk=TdNa 57 7 737 AddleA Lj l�fl.l G���s1.1 CJ u AIL TdNo. QWI,WSWSURANCEWAM3R lam Am dritheLioa>'seedoe snot have theinsurd eooeeagasiecltluedbyNbMduMG=WLaws atd that my scene m tliis peirrlit app)rafiai wanes dlis iec}mariat (Please check one) Owner Agent Telephone No. PERMIT FEE$ .. signature of Owner or Agent 6075 ' Date... :. �...... ,y RTq'1 TOWN OF NORTH ANDOVER F PERMIT FOR WIRING, �,SSlCHU$ This certifies that { .�-i-es-rr, ..l '�'t"� ..................... has permission to erform wiring in the building-of..... , ....................................................... at.... .......,North Andover,Mass. Fee s......... Lic.No'� C, . .... ....,. .... ELECTRICAL INSPECTOR. Check # — r5 The Commonwealth of Massachuse otn« Use Only Department of Public Safety Pef•" M. AO Occupancy i Pee CAecked BOARD OF FIRE PREVENTION REGULATIONS 527 1 R 1200 3/90 (!cave 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 ME ALL INFORMATION) Date C/ City or Town of /Vorth Aover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number)_ 4-%6 PlrctSrm 7-S?; Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes Q No ❑ (Check Appropriate Box) Purpose of BuildingAle-Ll C,f9n$frUCf lore Utility Authorization NO. T /� 1 b 0 Amps I Exisst g Service �/ /L�_Volts Overhead !� Undgrd❑ No. of Meters New Service IN O Amps 0 / 27 Volts Overhead ❑ Und rd N t Z 0. of _ 8 ® Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work O U(1^e ev a i0o 1,1jAP6L/�°t`_, � 7 e,at�d c�,61 e a�,d. a ppb insti No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KYA No. of Lighting Fixtures f Swimming Pool AboveIn- grnd. ❑ grnd. ❑ Generators RVA No. of Receptacle Outlets No. of Oil Burners Batter EUnitancy Lighting No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones /( No. of Ranges a 8 No. of Air Cond. Total tons No. of Detection and InitiatingDevices No. of Disposals No. of H�ts TTons ToKW No. of Sounding Devices No. of Dishwashers / Space/Area Heating KW No. of Self Contained Detection/Sounding Devices Nq, of Dryers Heating Devices IW Local❑ Municipal [:)Other N(:. of Water Beatersf No. of Sis �nf Ballasts LowWirVoltage e,) N Hydro Massage Tubs No. of Motors Total HP cakg e OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO[] I have submitted valid proof of same to this office. YES❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE fffoj( BOND ❑ OTHER❑ (Please Specify) _Pgvde,� -!k 23 6 Estimated Value of Electrical Work $ 1%0 •00 Exp rat on Date Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: t� FIRM NAME r0 K i, al) LIC. NO. 3q7 f•3 f Licensee J,rO 7& S Signature LIC. NO. Address 4- Pok itIV. Atufover ,04. p Bus. Tel. No. 17-3�s Alt. Tel. No. t 1- �22o,26ff4 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE 90 Signature of Owner or Agent 1 Date-15, HORT1y TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACNUS� This certifies that !- E. . . — �.- i-•-- . . . . . . . has ermission to erform . . . . . .� . . . . . . P P plumbing* in the buildings of . . . . . . - . . . . . . . . . . . . . . . . . . . . . at . fJ . .�._ : .+. . . ��'��� -,:-�`.�. . . �:,. . . . ., North Andover, Mass. Fee ��?. .Lic. No. . . . . . . . PIUM�BiJVG INSPECTOR V Check 6515 �� d 6 � � � A M MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date f a T G Building LocationOwners Name i. Permit# c5 Amount Type of Occupancy New El Renovation Replacement Plans Submitted Yes No El FIXTURES SLS)l$1IC goo 1SIC FLOQt 3�II FIDCR IMELO R 4M HIM 5M Kf CR 6IIi FIDQt 4 '7M F11= gm NJ" (Print or type) Check one: Certificate Installing Company Name r Corp. Address Partner. S k CA Business Telephone — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 0 Agent 0 1 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 Massachusetts State Pjqmbing Ct@e and apter 142 of the General Laws. By: igna u e 01 Licensedm Type of Plumbing License Title City/Town License um Master ® Journeyman El APPROVED(OFFICE USE ONLY OttYee 11" only The Commonwealth of Massachusetts Department of Public Safety Permit 49' A�,v BOARD OF FIRE PREVEN71ON REGULATIONS S27 CMR 1200 3/90 occupancy s Fee Checked (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK NI work to be performed In accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK ORS ME ALL INFORMATION) Date cf- /V City or Town of Ort' Aro Q(lL!' To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) PiCcl5gQ]'S"t; Owner or Tenant Lava.se 13vr1 e_ Owner's Address Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box) Purpose of BuildingA&t✓ Ug nS t u(_f10 rr Utility Authorization NO. rtMP Exist g Service ILO Amps f 2 o / 2Y6 Volts Overhead C Undgrd❑ No. of Meters New Service 0 0 Amps l Z 0 / 2 T Volts Overhead ❑ Undgrd® No. of Meters_ Number of Feeders and Ampacity Location and Nature of Proposed Electrical WorkU 7 re_ e4/to-,,7S r41&io1? t y'i QUej. • � n e,Q�,d c,�lbl e an a ppl ,n;sh No. of Lighting Outlets No. of Hot Tubs No. of Transformers TRVA No. of Lighting Fixtures f Swimming Pool AboveIn- grnd. ❑grnd. ❑ Generators RVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting .Lattery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones JU 5m61�1 No. of Ran es Total No. of Detection and �& g No. of Air Cond. oC tons 'Initiating Devices No. of Disposals No. of Heat Total Total Pumps T s No. of Sounding Devices No. of Dishwashers / Space/Area Heating KW No. of Self Contained Detection/Sounding Devices_ No. of Dryers Heating Devices KW Local❑ Municipal ❑Other Connection No. of Water Heaters 1 Signs Ballasts No. of W iinoltage &Agn-ej No. Hydro Massage Tubs No. of Motors Total HP g OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liabilit Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES F-1 NO NO y I have submitted valid proof of same to this office. YES❑ NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE [V BOND ❑ OTHER❑ (Please Specify) T�Nvf%� � ti�fiV2--?,L6 Estimated Value of Electrical Work $ 1 5 o •00 7 (° tp rat on ate Work to Start Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME ro �( t. l� LIC. NO. q1 13 f Licens ee sn5. S S Signature g re LIC. N0. Address q�s'F /j Qc/er d, 0 Bus. Tel. No. 17-335 i Alt. Til. No. 2!J_26 OWNER'S INSURANCE WAIVER: I am'aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent � v C9 Fq G' h`� JIM L U1V1iV1U1V VVVA4 j n Ul'lnr>ta x>t�,nv.wi i� �••qw� -�••� DEPARBIENTOMB ICSAFEIY Permit No. BOARDOFFIREPRE EMONRDG LWONSS1 a 8120 Occupancy&Fees Checked APPLICATION FOR PERAff TO PERFORM ELE=C,AL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 ,?LEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat 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) ` Owner or Tenant G2 Owner's Address Is this permit in conjunction wi a buildin rmit: Yes No (Check Appropriate Box) an 3�/ Purposeof Building Utili tyAuthoriztio . Existing Service gn6flpsVolts Overhead derground a No.of Meters New Serviceps / t- olts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tuba No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool AboveBelow Generators KVA ground ground rl No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections rHyWdr-o Heaters KW No.of No.of Si Bail is assage Tuba No.of Motors Total HP ER• COWW Piva>attbthe otMassacfn s Laws acamerltLiabt6g+]rtsul:lc� lttdidrgCortlpi� orilssllbt;�alegtlivala:t YES ` NO subm�ladvalidptoafaf blhe0ffim YES lfnu�vchetlzd plewnii *Qtetypeef the box. /— BOND o � o ) FvW 3� Estirn*dV"ofEktz lWctk$ S� D& nn ' uttder R�cfpetjuty. cJ q -e��;c C l_:�l � Lioerti9eNa 1 LimmNo Ls �'��c lC�n � � Btls�ss'Ibl.Na ALTel.No. 'SINSURANCEWXVEP,Iam thattheLiaagedotstrothequivalMtascagtmadbyMmsad>nMG=WLam sigtlahne cn dis petmR app5ra6cn wanes dig tagtmartat check one) Owner Agent Telephone No. PERMIT FEE$ Signature o wne en �" ��� _ 2 � � � 9^©� � Sc�� �, �� f