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Home My WebLink AboutMiscellaneous - 53 BRIDGES LANE 4/30/2018 (3) 0 w $ w .d 0 N N 0 �m 'o r i --- - —_--- -- - -- - ----- -- --- ----- — _ �I FORM - U = LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT Pa v l H ) vvi v)q led PHONE `17 k '13 0 ASSESSORS MAP NUMBER 1.0 ' 7 LOT NUMBER a C7 SUBDIVISION 11 LOT NUMBER STREET 53 j3 r ick c,t S la N • STREET NUMBER ME OFFICIAL USE ONLY GI S ................................................... MEMO ■ MMEMMEMMME M■. COMMIMEND_A�}TIONS OF TOWN AGENTS MM PI, 'EEEEEMEMMM�MMEMEEEEMMMM DATE APPROVED CONSERVAlION ADMINISTRATOR f DATE DEJECTED COMMENTS '`�-g- `s • \`� 1 a� s A. gQ NVQ A, ,L DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED FOOD INSP OR-HEA1,TH DATE REJECTED DATE APPROVED ,<__ioC PECTOR-HEALTH DATE REJECTED L. CYTONS e'sd , `712-/ DATE APPROVED DATE REJECTED DATE �� _ ��Z� s� �� ' �� _� FORM - U = LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT Paul 1 ) m Wt ed PHONE q7 `{ 3 6 5&S-9 ASSESSORS MAP NUMBER iD LOT NUMBER oZ C� SUBDIVISION LOT NUMBER STREET 53 k3 r 1 J r,e3 STREET NUMBER .......................... OFFICIAL USE�ONLY... M0. a�. .sT. _ C.K COMMENDATIONS OF TOWN AGENTS 7�h OUT 00 5� DATE APPROVED CONSERVA^ ION ADMINISTRATOR n ' (1_ DATE DEJECTED COMMENTS ty " `s lc \\�' 1 d� ti qO 1+� DATE APPROVED TOWN PLANNER DATE REJECTED CONM4ENTS DATE APPROVED FOOD INSP'' OR-HEAITH DATE REJECTED DATE APPROVED C PECTOR-HEALTH n DATE REJECTED 1 COMMENTS !i Y Z- ✓ c r X11 / c %.^�- F y/c 6 v �,�}S��a.•� C PUBLIC WORKS-SEWER/WATER CONNECTIONS �S Q DRIVEWAY PERMCT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE s TO'd IU101 t 7l 71_A-A EK's41 Yo ped • �- tai � t C7 i QA�io ;,Attf�or ' OF 1 ' f y, LOCATION OF STNUCTURE(S �. �l:r I T SFD ON LINES Oi OCGUP�(TIO(v \\\ , )~ fir' WT 72 -A ONLY. A MORE ACCURATE LOCATION \ Will REQUIRE AN INSTRUMF i \L`• �5 +Y �,� SURVEY. \ a LAURETANI Fd'-'r- Lam►717 \. V 1 } A 11 34311 5 S t ��' ►dK of�C _IcA 1 Scale: S. LMPRETAN, AMERICAN SURVEYING COMPANY � I,JaISh PEGISTERED LAND SURVEYorl, 1264 Main Street, Waltham. MA 02154 (781) 893-6477 10 HEREBY CERTIFY. THAT THE '.BOVE MORTGAGE INSPECTION _5 BARED FIN Mortgage Inspection Plan -TJNNECTION WITH A NEW DATE 1c:}, ccs RGCOR 6q ATS. :1 101 MAGE AND IS NOT INTENDED CLIENT --COUNTY REGISTRY OF DEEDS 1R REPRESENTED TO SE A LAND 80(�c —PI\C3E , L.C. Cen. N )R PROPERTY LINE SURVEY. NO CLIENT REF, N �_ PLAN REFER NCE:_ t7�-�T4 — :ORNEAli WERE SEI IT BR J O x MM DRAWN PER TOWN POF X A ASSRSSOR'S ISED FOR ESTABLISHING FENCE. THE LOCATION OF THE IMPROVE- ADDRESS: RN - IEDGE OR BUILDING LINES. THE MENTS SHOWN HEREON EITHER WERE AND AS SI4OWN HEREON IS BASED IN COMPLIANCE WITH THE LOCAL BORROWER: )N CLIENT FURNISHED INFORMA- APPLICABLE ZONING. BYLAWS IN ION AND MAY 8H SUBJECT TO EFFECT WHEN CONSTRUCTED (WITH SUBJECT DWELLING LIES IN FLOOD ZONE j 'URTHEA OUTSALFS, TAKINGS, RESPECT TO HORIZONTAL DIMUN• AS SHOWN ON NATIONAL FLOOD INSURANCE PR RAM FLOOD j :ASEMENTS AND RIGHTS OF WAY. SIONAL REOUIREMENTS ONLY), OR IS INSURANCE RATE MAP DATED' 0fift 2 10 RESPONSIBILITY IS EXTENDED EXEMPT FROM VIOLATION ENFORCE- COMMUNITY — PANEL N 1118IN TO THE LAND OWNER OR MENT ACTION UNOEF1 MASS.G.L.TITLE )CCUPANT,IT 15 NC37 INTFNDGU TO VII,CHAP.40A,Si;C.7,UNLESS CT'HER• FIELD-Cy j RAF I I-D GHE 'KE 3E RECORDED. WISE NOTED OR SHOWN HEREON. BY S DATE I > —2Ir F.S. PGE. !:?g TO/TO'd N13IHS3N 01 .13mITS NHOIZ03" WO`dd bZ:OT 666T-22-6 W + �'� .ter+^"_ �"'•.�✓^` p 1 COA I � � I r——, lu f Xi Q 'EXIS i INiG Frio ; `.\ 0 i i L ELCVAT i N,S 4 r TOP FN w 14f�3� I iouS E-OUTLET ST INLET } ST OU TLET f X54 R 40-37, 9,130 JINLET i� BMX OUTLf�� t4C.2 ' PI (fit.! ? - ° '� . y i.. i...!' l '3� t i ��'1 `V �✓ I..J4J �i ;7`tSI,E ISLT� E 'F�O.lC. 1 GERYiFY ENS Si=MG 9YSTE77p„e Y",%S n�PL—LEG AS,.S-HO R " { ?3 Y T IS it !�x�J.E ;� L"t.AS A b'�ARRN Y OF THE SYS?�Q o,; «: �� -� r 10N ;iS t-' r ! i�R S +D [ " DLT : x r SCALE #. AT 8 7 �•_}.., ate- t.-�� ' - - 06 BO/Y ) W r r w in ,i•.r-.rJ,i..-..•w�.�-+�.MiwA.✓.,+.�+arr.-+...+•.�. .-F:+y�v...+r .r.np.y.�,rt...w.+»+.�++t..r---.•-,^^ w.+Gvn. _ _ _- .._.r..... ., ! R Y b - • a • .. F � zip�,q. Cyny �{r4 +!, v0Y b� '?' h M tl Sr. � .y py. - .. - +.. .. r � .. . i�A � a 3 t 4``' '� r^i ¢.a Y•>��'va J. T �,+: '� � - , a � A R d i �' i i d a;. �� s TOWN OF NORTH ANDOVER BUILDING DEPARTMENT a APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING i BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1-SITE INFORMATION 0 1.1 Property Address: ii 1.2 Assessors Map and Parcel Number: 5-3 Gr %JAe-s d_ G �0 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: i I Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard R red Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Pafrl6-ILt Smart UUai5 k Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print Address for Service: O Signature Telehone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number wn Address S P t o o '`✓d A n J, 'f e r Y`z,S Expiration Date Signature lWelcphone ,,,�—/ ,Fy 3a SQ S r 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number M Address o Expiration Date ^z Signature Telephone !1/ 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 rmit. Signed affidavit Attached Yes.......0 No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Cz o`�Y l'a bye 2- -F- Q ald tit. G v7 X 4 r 0 ` Q ct=' 6ka-t- . /U u c lyi v� ti va cwt -t/ or SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be �OFFICIA USE UIYI}Y Completed by permit applicant 1. Buildin$ 5 ®� (a) Building Permit Fee I Multiplier 2 Elec 'cal (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby au nze to act on M Mbclal i e tive to�work authorized by this-building permit application. `Od ��tiwx.ct 2 / Si iahue of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR 1UvMERS 1 2 3 SPAN DINIENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE - The Commonwealth of Massachusetts r Department of Industrial Accidents o!f/ce o//nvesUga1/ons 600 Washington Street • Boston,Mass 02111 Workers' Compensation Insurance Affidavit Y qty �U P1 6 V-e phone# 0 1 am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity h. t, C] I am an employer providing workers' compensation for my employees working on this job. company name: address. city, phone#• insurance co. policy# 1 am a sole propriet r,general contractor,o0 homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: U We r(2 v -t-7d 1,1 address: ids civ Yl t lf) l J4,i phone#: SCI y7 Y U G e� to �l _rlS v- o d aao 1? (0 :t company name: address: S.itye phone#• insurance co. policy# ssr Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or one vtears'imprisonment as well as civil penalties in the form ors STOP YORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of investigations of the DIA for coverage verification. I do Hereby certij r the pains and penalli s ofp er)ury that the information provided above is true and correct. l Signature -Y1"1. Print name �� (jT� ]y f V11 ��] `F Phone q7? '-f 30 SCJ official use only do not write in this area to be completed by city or town official cite or town: permittlicense N_ nfluilding Department OLicensing hoard check if immediate response is required pSelectmen's Office OHealth Department contact person: phone#; nOther L Devised 3/93 P1A) - RESIDENTIAL CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign it. Notice: All home improvement contractors and subcontractors engaged in home improvement contract- ing,unless specifically exempt from registration by provisions of Chapter 142a of the general laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and statusshould be made to the Director,Home Improvement Contract Registration,One Ashburton Place,Room 1301,Boston,MA 02108. P.A.HIMMER GENERAL CONTRACTOR 10 HAGGETTS POND RD. ANDOVER,MASS 01810 978-430-5657 Designated Registrant's Name: Registration Number: Salesperson's Name: —7 P.A.HIMMER GENERAL CONTRACTOR This agreement is made on ! _/0 –dL 020 between 10 HAGGETTS POND RD. (DATE) —AND-00-MER fifi-A-9 of (ADDRESS) (PHONE NUMBER) hereinafter called"Contractor"and _ `{ r)�`_ + (OWNER) of �hdo,f Mass 97Y089 g 432- (ADDRE (PHONE NUMBER) hereinafter called"Owner". I. DETAILED DESCRIPTION OF WORK TO BE PERFORMED Contractor agrees to perform in a good and workmanlike manner all work detailed below. Such work consists of the following: j U If DETAILED DESCRIPTION OF MATERIALS TO BE USED Materials to be used in performing the above described work consist of the following: et f {/ t f R , XI. COMPLETENESS OF AGREEMENT FOR EXECUTION The Owner is hereby advised that he should not sign this Agreement unless and until all blank sections have been filled in or marked as void, deleted or not applicable, nd until all exhibits and related or referenced documents that are incorporated herein are attached hereto. XII. COPY OF AGREEMENT TO BE GIVEN TO OWNER This Agreement is governed by the Laws of Massachusetts. It must be executed in duplicate,and an original signed copy hereof given to the Owner at the time of execution. No work under the Agreement shall begin prior to the signing of the Agreement and transmittal to the owner of a copy thereof. RIGHTS TO CANCEL The owner may cancel this agreement if it has been signed by the owner at a place other than an address of the contractor which may be his main office or branch thereof, provided that the owner notifies the contractor in writing at his main office or branch by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. See attached Notice of Cancellation. HOMEOWNER: DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. o CC) Owner's Signature Date Signed Contractor's Signature Date Signed H- GG 25M 6/92 k C Town of North Andover o& VAaRTH %-Ib "S 'Y Building Department o r - 27 Charles Street ` North Andover, Massachusetts 01845 m (978) 688-9545 Fax(978) 688-9542 9q`°`�"°•-�• �4 °gA I SSACHUb� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit 9 the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in/at: Facility location Signature of Applicant —00 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. I .�r " ✓{Z� �DUI)7,0�2(I�P•CLGCfL O�/a./U/,pd�lLCJ2Ll '7Y°'��' •'i � BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 021443 Birthdate: 05/28/1952 Expires:05/28/2002 Tr.no: 26175 Restricted To: 00 PAULA HIMMER 10 HAGGETTS POND RD (�•"' ANDOVER, MA 01810 Administrator I ;J/ce l/�a)�t4nmeU�Pa�.[/rO�✓F'�slddacltaife��d '. HOflE INPROMENT CONTRACTOR Registration: 104479 Expiration' 1/14/02 Type: Individual PAUL A. HINMER GENERAL CON Paul Hisser 10 Haggetts Pond Road ADMINISTRATOR Andover HA 01810 I I qA PIC a 1aA �1 l��i L ,uaaFj poddnS joi- _Lj, � tX 1° Sr�d S fan-2 T cat sy 1 n VT/ Fj � P 2� S n so uoJ1 Jo Paso �0ON s 4� 1 Pl S ar. •ti • f � r i t 5 �IV 0 A nid0 ass -Pr0 o Se. Aa 1 �N A An J �- dT(UYL r1l IYl 2 GU ` 7—E-00 S oon tC�Zir�1 poS�S De O\k -71 ll?T A X 1;;L remiih C'ov1GrC� to uj II 04 o IP a1 �l, JO jiIL L L L LL AL L al o� 0 1ULM WP�_ �j SSP a p V i [-Acei �� dun � a I S TZ 1 i loo�Q e a� S s e o ON ' � k ' R '� i � t. a.J Location ` -2 1/ /11��-�� 0 v `• No. j /' Date { ORTM TOWN OF NORTH ANDOVER Of "G. , 3: . 0 0 9 ` Certificate of Occupancy $ s i • "ems � • i '',s'•^ <�' Building/Frame/Frame Permit Fee $ s+cHust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 657 • � ��- "..-..� Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER. DATE ISSUED. rn 6--l- SIGNATURE: SIGNATURE: Building Commissioner or of uildin Date SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: X /' G Map Number Parcel Number 17-1 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re uired Provided v 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System 0 _J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record Name(Print) Address for Service: Signature g Telephone 0.' 2.2 Owner of Record: + Name Print Address for Service: O Z M Signature Tele hone _ SECTION 3-CONSTRUCTION SERVICES go 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: O License Number M Address 1 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ v Company Name rn Registration Number Address r Expiration Date �^ Signature Telephone v• V- SECTION 4-WORKERS COMPENSATION(M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: } 1 ;` "� t SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICE USS"ONL Completed bV permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC j 5 Fire Protection (p 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERSAGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 I, 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/A ent Date ' . PON a - _< NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS I[EIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE xAORT11 ® �' E L TVwMnO 0 �� ...:. Andover No. i �o-- L03 dower, Mass.,_.. / Ii9S�RA7E D G`Ppt�! H PER IT T D BOARD OF HEALTH Food/Kitchen Septic System Food/Kitchen CERTIFIES THAT........... ...................... BUILDING INSPECTOR .................... "" Foundation has permission to erect............ .. buildings on ..-S. .......................... ...... .. ............... Rough ... .... . ............................. to be occupied as provided that the arson ecce...: ..................... ................................................................................................. Chimney. P p g this permit shall in every respect conform to the terms of the application on file in this office, and to the provision of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. VIOLATION of the Zoning or Building Regulations Voids this Permit. PLUMBING INSPECTOR Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR ...................../...'1.. .l�!A ....................................... Rough Service "OBUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough No Lathing or Dry Wall To Be Done Final Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT' Burner Street No. SEE REVERSE SIDE Smoke Det. IAORTtt 3? 6•'r �'f6 OL tO y Town of North Andover Building Department ` . 27 Charles Street �4SS�IGHU`sF�� North Andover MA 01845 Tel: 978-688-9545 HOMEOWNER LICENSE EXEMPTION Please print. i' DATE JOB LOCATION Number Street Address Section of Town "HOMEOWNER 53 7Z/_,0�7o/-914n62 Number Home Phone Work Phone PRESENT MAILING ADDRESS Z,—n-j�4� �2 Oo✓e�� f/9Y5__ City Town State Zip Code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six 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 109.1.1) DEFINITION OF HOMEWOWNER: 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 to six family dwelling,attached or detached structures ac- cessory to such use and and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official, i a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance 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 No.Andover Building Department minimum inspection proc res d requ' ments and that he/she will comply with said procedures and requirem ts. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note:Three family dwelling 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0 Construction.Control. Date..S.V) 11 ,5 .. 11164. r►Ow7�y TOWN OF NORTH ANDOVER o3a.' .. .• 09 PERMIT FOR PLUMBING =.- This certifies th ......�-........Y .... � ..................................................... . has permission to perform....��.�- ......!'> .....f ............... plumbing in the buildings of...... 6.�.L.......................................................... at..........3. ........��.....�.�...�..�..?�....... ........................ North Andover, Mass. Fee...Y �.....Llc. No. 2.�i k.�.. ....................PLUMBING INSPECTOR.................... Check# Q,493 'n^ 2-'2 co 1�`� o , -' ggt�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ��" /� " c'�' MA. DATE S"a$✓a Q/5� PERMIT#_ _— JOBSITE ADDRESS n"3 e r^ i 6�g eS LI-1 OWNER'S NAME W S/S TM OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT.J4 PLANS SUBMITTED: YES[INO ❑ FIXTURES Z FLOOR-' BSMT 1 2 3 4 S 6 7 8 9 10 11 12 13 14 BATHTUB Q CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS _1 .DRINKING FOUNTAIN V DISHWASHER FOOD DISPOSER 3 FLOOR/AREA DRAIN INTERCEPTOR QNTERIOM :9. KITCHEN SINK LAVATORY - ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES W TER PIPING OTHER INSURANCE COVERAGE: have a current liabilityinsurance policy or its substantial equivalent which,meets the requirements of MGL Ch.1.42. Yes ff No❑ _ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Mont I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the will be in performed under the permit issued for this application wi 1 and that all plumbing work and Installations best of my Knowledge P 9 Pe � compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of a General Laws. PLUMBER NAME 9 y,k Yj'u v-5 e S S SIGNATURE LIC# ,Q MP❑ JP❑ CORPORATION ®# PARTNERSHIP Q# LLC []# _ COMPANY NAME ►J 9 e S` / ��Y`` �^t ADDRESS: ✓'el 5 CITY %`'� S✓'c v a STATE Yom_ ZIP 0J 97 EMAIL ej YS-e S S 10/Q tom; L 1� VP4/r 2 a 4 .-41 P 1 TEL 1 , - 4 Y9— a J'/0 CELL 9,2s -8J S - ?8 6� FAX J i The Commonwealth of Massachusetts Department o IndustrialAccidents . Depa f , ress Street,Suite 100 1 Con g Boston,MA 02114-2017 www.mass.gov/dia 'fib �V�v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plum ers. TO BE FILED WITH THE PERNUTTING AUTHORITY. Please Print Legibly Applicant Information , Name (Business/Organization/Individual): ►�j`. �T G�S f '� P a r� G� Address: (� � City/State/Zip: T % -I 5��' P"-� Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.p I am a employer with _employees(full and/or part-time).* 7. ❑New'constrUction employees workin for me in 8. Remodeling 2.❑I am a sole proprietor or partnership and have nog ❑ any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10[]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12 &Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance? 14.❑Other 6.❑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.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. ce or m employees. Below is the policy and job site I am an employer that as providing workers comp ensation insuran f y information. Insurance Company Name: �,� p (o d � �CS A Expiration Date: �� Policy#or Self-ins.Lie.#: / [� e Job Site Address: �-3 ,-` d $e S (� y1 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 ies in the form of a STOP and/or one-year violator. copy of this statement ment,as well as civil ay be forwarded to the Office O Inveestigations of the DIA for insER and a fine of up to urance a day against thep coverage verification. I do hereby certi y under tl:e pains�anadpenaltiesf perjury tliat the information provided above is true and correct. � Date: 5' ' � �_ 3—e�•5' Si ature: 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#: P Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver'or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia � t J COMMONWEALTH OF MASSACHUSETTS PCUMBERSBASFITTERS ISSUES TH'E 10LLOWIS LICENSE . LICENSED AS` A JOURNEYMAN PL-UMBER . : MARK ;W BURGESS 6 OLD KEN:OA LC RDul TYNGS`BORO MA O1879-1023 05./O 1/1.6::..:::.:::.. 223613 , r r, �� COMMONWEAiLTH OF MASSACHU`SSTTS PLUMBERS FITTERS ' ISSUES TH1= FOLLOWING Lt<GENSE L I LENSED AS A MASTER PLUMBER ?� p MARK W BURGESS �� ,° �.n 6 OLD KENDALL RD TYNGSBORO MA 01879-1023:' t 1894:::..::>:. 5/01/!:6 <.::.. 223614 i .. �> l 9 COMMONWEALTH OF MASSACHUSETTS:. • • • PLUMBERSg1SF ITTERS. ISSUES THE FOLLOW ING;;l.1CtNSE ¢ . `D AS A PLUMBING—CORP REGI STERE MARK W BURGESS �1 r 6URGESS PLUMBLNG' & HEATINGy,INC. ',rj x� m ' .6 OLD KL:1 RD � � I TYNGS40R0 MA 01879-to23 0::>/O 1/1:6 .<.::.>:<;::;:>: 2 2 3615 ;, .COMMONWEALTH OF MASSACHUSETTS • •l 2:22101 A=11 Fel PCUMBERSeSFITTERS. ISSUES THE FOLLOWI Nf. I_.f C�N'SE LICENSED A5' A JOURNEYMAN PL-UMBER -< +cc` MARK W BURGESS _� n 1 6 OLD KENI):ALL I;D TYN5BOR0 MA 01879-1 w 229�0 : o /0l/1..:6 ; 223613 r ff COMMONWEALTH OF MASSACHUSETTS Wei VAI k • • • • • PLUMBERS SF I TTERS ISSUES THE' FOLLOWING LICENSE 3{ ' L I CENSE{�' AS A MASTER PLUMBER � 14 yj MARK. W BURGESS 6 OLD KEN<DALL RD TYNGSBORO MA 01879-1023 1184 ;o5.1ot/16 . 223614 llh OMMONWEALTH OF MpS�SACHUSETTS; << • -------------- PLUMBERS SF I TTERS ISSUES THt FOLLOWING ;LJ EN5E . .., R1*G I STERIrD AS A PLUMBING CORP M ARK ::W BURGESS l t1 lt3RGESS PLUMB LNG & HEAT I NGS I NC�' 6 OLD KEiJDAII RD fit ;y y\ J TYNGSRRO MA...01879-1023 p5.%O1/1,6: , :, 223615 Date..-.4...-.-Z4.i..`'.�................ • r►ORT{q TOWN OF NORTH ANDOVER s PERMIT FOR WIRING ..........��,tog S3�CHU55 This certifies that. !. A.. .�.�F' ..0......................................................... has permission to perform ...........�....... r-e- W a ch wiring in the building of................ .......................................................................................... � n at ....... ................ !.. .5...... ................., , .o, .orth Andover,Mass. Fbe....�' ?.:-.........Lic.No. .. "Z.B` .. 0 ljr l^ .f..... ... .......................................... F o-1 ELECTRICAL INSPECTOR � 'J" Check# 1 3 i ) A Vn' �e5 vyl � Z� ��- A Commonwealth of Massachusetts Official Use O ly o Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (leaveblank �M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL)NFORMATION) Date: I dlll� City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned g' e notlpeL,of his or her intentiog to perform the electrical work described below. Location(Street&Number) ! l `� �,Jg el (rn Owner or Tenant R,f Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd [j No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: l�, }ter S�ht.;,,r, 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 Lj' Swimming Pool Above ❑ In- E] jN o.of Emergency Lighting rnd. grnd. Battery Units * No.of Receptacle Outlets 1\() No.of Oil Burners FIRE ALARMS No, of Zones } No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No. of Waste Disposers j Heat Pump Number Tons KW No.of Self-Contained Totals: """...""............. Detection/Alerting Devices No.of Dishwashers I Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of,Devices or Equivalent No.of Water KWNo.of No.of Data Wiring: Heaters Signs - Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: r / Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: `�'�tiu (When required by municipal policy.) Work to Start: J,/l ti� 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 M BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . /Vh dei, E110,ft L t C. LIC.NO.: Licensee: Xd �, Signature _ LIC.NO.: (If applicable,ente ` xemp "in the license number line.) Bus.Tel.No.• "Z Address: L, 11A U l�61 Alt.Tel.No.: 7YI 10 17a *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..$ �(5— ❑ 2012 Massachusetts Eiectrical Code Amendments 527 CMR 12.00§Rule 8: In accordance.with the provisions of M.G.L.c. 143,§3L,the e permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the 44 notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: tr Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Y Failed 0 Re-Inspection Required($.) ❑ Inspectors mmen -3 Inspectors Sign ure: Date: FINAL INSP TION: Pass 0 V Failed❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com _ , . The Commonwealth of 1V1assachusetts DepartmentoflndusftialAccidd nts Office of Investigations 600 Washington Street .Foston,MA 02111 www.�nass:gov/ciza Workers'Compensation Twurance Affidavit:Builders/Cony°actorsfFlectricxansC khibers Applicant Information Please Print Legibly Name(Business/Organi'zation/In�dividual): Address: City/State/Zip: ' �,'�,-� /�!/' (U Phone#' 7 Y' i�_3 7 c Are you an employer?Check the appropriate box: Type of project(required): 1.[l I am a employer with 4. El am a general contractor and I 6. ❑New construction employees(full and/or par-time)* have ned the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7. ❑Remodeling ship aud`have no.employees These sub-contractors have 8. ❑Demolition. working for me in any capacity. workers'comp.insurance. gr ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.[I Electrical repairs or additions required.] officers have exercised.their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions c.152 14 and have no Ys com . �§ ( )� 12. Roofre airs myself.[No worke p �] p insurancere . employees.[Nb workers' �ired] 13.❑Other comp.insurance required.] kAny applicantthat checks box#I must also fill outthe section below showingtheir workers'compensationpoHcy Information. i Homeowners who submitthis affidavit indcatingthey hie doing allworM and then hire outside contractors must submit anew affidavit indicating such. lContractors that checkthis bob must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am are employer that is pYoviding workers'compensation insurance for my employees Below is the policy and jolt site in•fonnation. Insurance Company Name: Policy#or 8e7£ins.Lic.#: 30 ExpirationDate: Job Site Address: City/State/Zip: /V �•n �.� Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration.date). Failure to secure coverage.as rRuiredunder Section 25A of o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or ones-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA-for insurance coverage verification. Mo hereby certfy unifier fife pains andpenaftles ofperjurp that the ire,formation provided above is true and correct. Sienature• Date. Phone#: Official use only. Do not write in tliis 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 U. 4 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 ofhire,- express or implied,oral or wxitten." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or anytwo or more of the Foregoing engaged in a joint enterprise,and including the legal representatives of a*ceased employer,or the receiver ox trustee of an individual,partnership,association or other legal entity,employing employees. 06,ver the owner of a dwelling house having notmore 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,i£ necessary,supply sub-contractor(s)name(s),address(es)and phone alongwiththeircertif' cate(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 orLLP does have employees,a policy is required. Do advised that thisaffidavit maybe submitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being regaested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain,a workers' compensationpol e,y,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 thatthe affidavit is complete andprinted 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/Hcense number whichwill be used as a reference number. In addition,an applicant thatn ust subnAmultiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or towiu).'A copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit-id on file for fature permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, r please do not hesitate to give us a call. The Department's address,telephone aid fax number: `rho Commox�wwoalth of MassaeliUsetlti Mpaximen't Qf1hdu&1a1 Aeeidenta Qfte offAwstigatio= 600Wmhiag� Sfreet Boston,MA 0.21.It Tel#6XM217-4.900 eA 406 ox 1-877,:1 .SSA Revised 5-26-05 Fax#617-727-7749 wWwaaagov/iia I { GOMMONWEA►tIH OF MASS CHI SETTS s ' Q BO 'K L CTRtCIA145 ISSUES THE FOLLow LICENSE :: AS�A REG 'OURNEYMAN.:,ELECTRtI l C NADEAU 3 GLA J ; 1�A lOS.URN o��01- o 31 COMM9NWAll H OF°M 5 �. . ASSACHUSETTA EL CTR"C"I MS ISSUES THE :FOLLOWING LICENSE AS q 1 REG°�siR13 MASTER ELECTRO Cl-;AN NAB EAI7. ELCGTR I C LC •11liES .G N/IDEU ? S �,•1 8EA0{ Sof ET lz MA 01801 2b5$ - ,J 20�+ , � , .0 713.1 4 ... ;:::. 3.8997