HomeMy WebLinkAboutMiscellaneous - 526 WINTER STREET 4/30/2018Date .a.[�.I. I
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
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This certifies that ............... I . ...... U....... % . A
.....
has permission to performIA %—
..... .................
.....................
wiring in the building
,"of .......... r -.*k ... C,
at ... ........ . ......... ..... . WIvAndover, Mass.
Fee b-ZY
% . .......... Lic. No . . ...t........
Check#
12435 1
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C'.mmmweatU e/ NamacAettd Official Use Only
ec77 Permit No. 4
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BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 7/6/15
City or Town of: North Andover To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) 526 Winter Street North Andover
Owner or Tenant Doug Schmidt Telephone No.
Owner's Address 526 Winter Street North Andover
Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box)
Purpose of Building Residential 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: Wire septic pump, float switches and control panel
No. of Recessed Luminaires
No. of Ceil: Susp. (Paddle) Fans
,,,y ue wu, mu by the ,ns ec,ur ul yr fres.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑In- Elo.
rnd. rnd.
o Emergency Lighting
Baftery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection andInitiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
g
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
. . """"
........
IK
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
No. of Water KW
Heaters
Heating Appliances Kms,
No. of No. of
Signs Ballasts
Security Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors 1 Total HP 1 /6
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ijdesired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 7/11/15 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 X BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: David W Meehan ^ r .- � A� I LIC. NO.: 8126A
Licensee: Uayiayy Meenan Signatu er( ///,l1J '� LIC. NO.: 8126A
(Ifapplicable, enter "exempt" in the license number line.)—V—'— Bus. Tel. No.: 978-587-7518
Address: 4 Mulberry Drive Peabody, MA
Alt. TCI, No.: 978-535-4022
*Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE. $
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The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
< Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers.
TO BE FH,ED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): David W Meehan
Address:—4 Mulberry Drive Peabody, MA.
City/State/Zip: Peabody, MA 01960 Phone #: 978-535-4022
Are you an employer? Check the appropriate box:
1.❑ I am a employer with employees (full and/or part-time).* .
2.® I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.C] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.C] I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.,
6. Q We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. E] Remodeling
9. ❑ Demolition
10 [] Building addition
11.nx Electrical repairs or additions
12.E] Plumbing repairs or additions
13.E] Roof repairs
14.FJ Other
—I)' apY,.UM�< MUL caeeus oox rrr mast also nn out the section net showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' camp. policy number.
Yam an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company N
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 6�2 (,( l fA e f 5Z City/State/Zip: 114A • AhLI 'Al� YVC,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby cel ' under fire pains and�ena ies of perjury that the information provided above is trite and correct
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
7/6/15
Issuing Authority (circle one): ;
1. Board of Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person:
Phone
Cunningham Lindsey U.S., Inc.
P.O. Box 703689
Dallas, TX 75370-3689
Telephone (888) 738-8714
CLCAT@CL-NA.COM
Facsimile (214) 488-6766
***********************AUTO**3-DIGIT 018
794 T3 P1 95000058984
Building Commissioner or
Inspector of Buildings
120 MAIN STREET
NO ANDOVER, MA 01845
Cunnin fiham
l�Lindsey
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS Ch. 139, Sec 3B
1118215
1118215 25
MERRIMACK MUTUAL FIRE INS
ICE DAM
2/20/2015
DOUGLAS & LORRAINE SCHMIDT
526 WINTER ST
Claim has been made involving loss, damage, or destruction of the above captioned property, which
may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it
to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss
and claim number.
Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions.to,a building or
other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three; applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city or town and to the board of health or
board of selectmen of the city or town in which the same is located. If at any time prior to the payment
the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to
perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
Claim Number:
Policy Number:
Company Name:
Cause of Loss:
co
Ln
g
Date of Loss:
Insured:
0
Property Location:
Cunnin fiham
l�Lindsey
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS Ch. 139, Sec 3B
1118215
1118215 25
MERRIMACK MUTUAL FIRE INS
ICE DAM
2/20/2015
DOUGLAS & LORRAINE SCHMIDT
526 WINTER ST
Claim has been made involving loss, damage, or destruction of the above captioned property, which
may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it
to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss
and claim number.
Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions.to,a building or
other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three; applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city or town and to the board of health or
board of selectmen of the city or town in which the same is located. If at any time prior to the payment
the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to
perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and
forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall
extend to and may be enforced by the city or town against any casualty insurance policy or policies
covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were
initiated.
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested
party for amounts disbursed to.a city or town under the provisions of this section, or for amounts not
disbursed to a city or town under the provisions of this section.
On this date, I caused copies of this Notice to be sent to the persons named above at the addresses
indicated above by First Class Mail.
Cunningham Lindsey
Catastrophe Department
cicat@cl-na.com
800-867-3885
Date ✓�..:� � �.. .
NORTH
<«�� •otic TOWN OF N}#i ANDOVER
PERMIT FOR PLUMBING
This certifies that ...'... ... . .........�� �
has permission to perform.. . . . `... . `.` ............... .
plumbing in the buildings of . S. '/'4", .�
at.2 ``� ` ' { 1' C ......... , North Andover, Mass.
Fee ... ..... Lie. No... G3/ .� 7. ? ...... . ��
LUMBING INSPE TOR
Check # Ll
7783
e
MASSACHUSETTS UNIFORM APPLICATION FOR -PERMIT TO DO PLUMBING
{Pr'nt or ype}
MOSS.- fl e 2117 D ='rmlt rNr
\ ' , // ♦i�
Bu' ding Lation Owner's a „L
Type of Occupancy
New a Renovation 0 Replacementlir" Plans Submitted: Yes 0 No 0
B. P.
FIXTURES
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nstalling Company Name
address
Business Telephone 62 ,� � 3 0 A-�
dame of Licensed Plumber or Gas Fitter
Check ons: Certificate
0 Corporation
0 Partnership
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 1142.
Yes No . U
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy 1;1-11�- Other type of indemnity fl Bond 0
OWNER'S INSURNACE WAIVER: I am aware that the, licensee does not have the insurance coverage required by Chapter
942 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check ane:
Signature of Owner or Owner's Agent Owner p Agent
hereby certify that all of the details and information I have submitted entered) In ab ove-application are true and accurate to the Best of
y knowledge and that all plumbing work and installations performed nd r the permit Iss for this application will be in compliance with
.1 pertinent provisions of the Massachusetts State Plumbing lode a pt '1142 or thea eral Laws.
By Si na ure of Licensed lumber
Title
CiryrIown f
APPROVED (OFFICE USE NLI'} Type of License: LYNiaster uJourneyman
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License Number__
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1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR I
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STH FLOOR
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nstalling Company Name
address
Business Telephone 62 ,� � 3 0 A-�
dame of Licensed Plumber or Gas Fitter
Check ons: Certificate
0 Corporation
0 Partnership
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 1142.
Yes No . U
If you have checked yes, please indicate the type of coverage by checking the appropriate box.
A liability insurance policy 1;1-11�- Other type of indemnity fl Bond 0
OWNER'S INSURNACE WAIVER: I am aware that the, licensee does not have the insurance coverage required by Chapter
942 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check ane:
Signature of Owner or Owner's Agent Owner p Agent
hereby certify that all of the details and information I have submitted entered) In ab ove-application are true and accurate to the Best of
y knowledge and that all plumbing work and installations performed nd r the permit Iss for this application will be in compliance with
.1 pertinent provisions of the Massachusetts State Plumbing lode a pt '1142 or thea eral Laws.
By Si na ure of Licensed lumber
Title
CiryrIown f
APPROVED (OFFICE USE NLI'} Type of License: LYNiaster uJourneyman
OII v
License Number__
Location��
w No. / Date
2
TOWN OF NORTH ANDOVER
.. 9
Certificate of Occupancy $
sA��,�s �� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # ��90
.i
1846`i
�`'=—Building Inspofpior
„ TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAI RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
',%;'
BUILDING PERMIT NUMBER: DATE ISSUED: //0/0 lO 0
SIGNATURE:
Building Commissioner/I toi-6fBuildings Date
SECTION 1- SITE INFORMATION
1.1 Property Address:
52 6 5-TC?CE-r
1.2 Assessors Map and Parcel Number:
0 `fX
Map Number Parcel Number
N (� l7 \ Nc ` [A-
1.3p Zoning Information:
L
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Area Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
Required Provide R red Provided
Re red Provided
1
1.7 Water Supply M.G L.C.40. 54) 1.5. Flood Zone information:
Public ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal ❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSI3IP/AUTHORIZED AGENT
rilistoriC District: Yes NO
2.1 Owner of Record
5ZG
Name (Print) Address for Service:
9�
�i (�, S�---(°c n G E3 44 59
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Licensed Construction Supervisor:
t
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
Company Name
Registration Number
Address
Expiration Date
Signature Telephone
00
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SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 S 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 .......0 No ....... 0
SECTION 5 Description of Proposed Work check all
applicable)
New Construction ❑
Existing Building ❑
Repair(s) ❑
Alterations(s) ❑Addition
❑
Accessory Bldg. ❑
Demolition
5WtMV-(tte'� vix3L
Other ❑ Specify i
Brief Description of Proposed Work:
r'r-,( b C t 'rt o L,4 P tit 0 FC L°°C D C P t4, C- jc,k '5 ( N, G (lac G t2O U C,,A (f)
5WCt1-tt(tgCG PC�oL, '4NC.2EZC O0C(C f-\�(Q C0V(t�kG 1,,u(LC (77JE
a C(' -t0 r- (r) r?C4u PL1f CCk� (tv V6cat_ V6 "i t.z1E, IQr� fr\tA,< ct7Ek( G C
`COLu"rc trs(LL (3E- 0ACVC(LLF0 1[,(c -rt.( Gcc(A`tEL_ V4C"C(d CGAt,-C ColC�-r
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollar) to be
Completed b rmit a licant
OFFIt iA)C, USE (?NLY ,
,x. x
1. Builder g
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbin
Building Permit fee (a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5)
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, �t��oCt�� �e �Ce�tcec(1T ^, as Owner/Authorized Agent of subject property
Hereby authorize to act on
M/bcl;e(i`alf, in ail matters rettive work authorized by this building permit application. b-5
Signature otOmmer Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, 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
Si ature of Owner/Aent Date
NO. OF STORIES SIZE Sam
BASEMENT OR SLAB
RD
SIZE OF FLOOR TDvIBERS 1ST—fly— ;
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED 'TO NATURAL GAS LINE
o
In
�. FORM U - LOT RELEASE FORM '
g/81
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 �mc�a��7 �° Sccs�cc7� PHONE 9-T8 �V5 4459
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
W (c't-rca S-taCK-r 5 U
STREET ST. NUMBER
********* *****OFFICIAL USE ONLY ********�
DATE REJECTED
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
�� HORTN
TOWN OF NORTH ANDOVER
3r0, qua.".. '
OFFICE OF
A
BUILDING DEPARTMENT
400 Osgood Street
North Andover, Massachusetts 01845
D. Robert Nicetta,
Telephone (978) 688-95454
Building Commissioner Fax (978) 688-9542
HOMEOWNER LICENSE EXEMPTION
Please print
DATE: 6 �e A 5
JOB LOCATION: 526 S -t,
Number Street Address Map/Lot
HOMEOWNER D0 bGC_A15 C 5c wk ru< rr 9-7 G83 44 59 6 c7 49C 1( 9
Nam6 Home Phone
PRESENT MAILING ADDRESS
City Town
5 Z� t("(k -7c12 J5 -I tz E rr-'r
N1 A
State
Work Phone
V i coo 4,5
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
130.1RD OFAPPEALS 688-9541 CONSERVATION 688-9530 HE;1L r1i 688-9540 PLANNING 688-9535
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TOWN OF NORTH ANDOVER
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Certificate of Occupancy
$
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Building/Frame Permit Fee
$
r �ss�cNUBEt
Foundation Permit Fee
$
Other Permit Fee
$
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Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
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Building Inspector
25.00 PAID
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HOME IMPROVEMENT CONTRACTOR'a '
Registration 118668
Type - INDIVIDUAL
Expiration 04/11/97
MARK J DI PRIMA
MARK J. DI PRIMA t,
G� -7f Z NNY AVE
`. ' ADMINISTRATOR METHUEN MA 01844
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Date .............
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SS�CNUS�
This certifies that �.. (`, ( (. ..... /1....j/� . l` l
has permission to perform
plumbing in the buildings of .. ...-?............. .
,�, .......... ,North Andover, Mass.
a
Fee. °,}.•.`! vLic. No
............................. .
PLUMBING INSPECTOR
l
Check #
6104
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING /
{Print Or Type) "" � � -✓
Mass. pat Zoo— Permit #
Building Owners Nam '(
Type of Occupancy '�j
New ❑ Rowvation ❑ placement ltd' Plans Submitted: Yes ❑ No ❑
SUB-8SMT.
BASEMENT
IST FLOOR
2ND FLOOR
2R0 FLOOR
4TH FLOOR
STH FLOOR
4TH FLOOR
7TH FLOOR
STH FLOOR
Installing. Company Name �+?P�EeT �i .�r9mm,4 7A� t7
Ackfress -�r t_ 0.404MAA) I- AJ
11) CTWa6-AJ A 01rf�1�1
Business Telephone
Name of Licensed Plumber
Check one:
❑ Corporation
p Partnership
Certim ate
INSURANCE COVERAGE:
I ;have a current Ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ J.
if you have checked y=. 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 E& 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:
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 pe&rmed under the permit for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum and apteof the tears.
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Type of License: Master gam/ Joumeymah ❑
ldy� ► License Numbet 3 5
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7TH FLOOR
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Installing. Company Name �+?P�EeT �i .�r9mm,4 7A� t7
Ackfress -�r t_ 0.404MAA) I- AJ
11) CTWa6-AJ A 01rf�1�1
Business Telephone
Name of Licensed Plumber
Check one:
❑ Corporation
p Partnership
Certim ate
INSURANCE COVERAGE:
I ;have a current Ity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ J.
if you have checked y=. 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 E& 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:
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 pe&rmed under the permit for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum and apteof the tears.
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Type of License: Master gam/ Joumeymah ❑
ldy� ► License Numbet 3 5
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