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Home My WebLink AboutMiscellaneous - 53 OLD CART WAY 4/30/2018 (2) �3 DSD Cis ZT of` �.` i .- G i Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Numb, WPA Form 8B — Certificate of Compliance 242-879 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEI A. Project Information Important: When filling out 1. This Certificate of Compliance is issued to: forms on the John and Kristen Sullivan (Current Owners) computer, use Name only the tab key to move 53 Old Cart Way your cursor- Mailing Address do not use the North Andover MA. 01845 return key. City/Town State Zip Code 2. This Certificate of Compliance is issued for work regulated by a final Order of Conditions issued to: Paul and Maryann Maus Name October 1, 1997 (Extended 9/20/00) 242-879 Dated DEP File Number 3. The project site is located at: 53 Old Cart Way (Lot 7A) North Andover Street Address City/Town Map 107B Parcel 88 Assessors Map/Plat Number Parcel/Lot Number , the final Order of Condition was recorded at the Registry of Deeds for: Paul and Maryann Maus (Previous Owners) if different Property Owner( ) Essex North 5958 213-226 County Book Page N/A Certificate 4. A site inspection was made in the presence of the applicant, or the applicant's agent, on: 10/14/03 Date B. Certification Check all that apply: ® Complete Certification: It is hereby certified that the work regulated by the above-referenced Order of Conditions has been satisfactorily completed. ❑ Partial Certification: It is hereby certified that only the following portions of work regulated by the above-referenced Order of Conditions have been satisfactorily completed. The project areas or work subject to this partial.certification that have been completed and are released from this-Order are: wpaform 8b.doc•rev.12/15/00 Page 1 of Massachusetts Department of Environmental Protection LIBureau of Resource Protection - Wetlands DEP File Numbe, f WPA Form 8B — Certificate of Compliance 242-879 1 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP B. Certification (cont.) ❑ Invalid Order of Conditions: It is hereby certified that the work regulated by the above- referenced Order of Conditions never commenced. The Order of Conditions has lapsed and is therefore no longer valid. No future work subject to regulation under the Wetlands Protection Act may commence without filing a new Notice of Intent and receiving a new Order of Conditions. ® Ongoing Conditions: The following conditions of the Order shall continue: (Include any conditions contained in the Final Order, such as maintenance or monitoring, that should continue for a longer period). Condition Numbers: 44 C. Authorization Issued by: North Andover /Q ,QJ Conservation Commission Date Issu nce This Certificate must be signed by a majority of the Conservation Commissi n a copy sent to the applicant and appropriate DEP Regional Office (See Appendix A). Signatur Z17 ZX4.1 nd On Of 0 J e.r a�Q3 Day Month and Year before me personally appeared to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. �7'rnG✓ � � � � / Notary Pubic 01My comnifssiog expires wpaform 8b.doc•rev.12/15/00 - Page 2 of I .. S ILIMassachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands DEP File Number: WPA Form 8B — Certificate of Compliance 242-879 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Provided by DEP D. Recording Confirmation The applicant is responsible for ensuring that this Certificate of Compliance is recorded in the Registry of Deeds or the Land Court for the district in which the land is located. Detach on dotted line and submit to the Conservation Commission. To: North Andover Conservation Commission I Please be advised that the Certificate of Compliance for the project at: Project Location DEP File Number Has been recorded at the Registry of Deeds of: i County for: I Property Owner and has been noted in the chain of title of the affected property on: Date Book Page If recorded land, the instrument number which identifies this transaction is: If registered land, the document number which identifies this transaction is: Document Number Signature of Applicant wpaform 8b.doc•rev.12/15/00 Page 3 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection -Wetlands WPA Appendix A — DEP Regional Addresses Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Mail transmittal forms and DEP payments,payable to: Commonwealth of Massachusetts Department of Environmental Protection Box 4062 Boston, MA 02211 DEP Western Region Adams Colrain Hampden Monroe Pittsfield Tyringham 436 Dwight Street Agawam Conway Hancock Montague Plainfield Wales g Alford Cummington Hatfield Monterey Richmond Ware Suite 402 Amherst Dalton Hawley Montgomery Rowe Warwick Springfield,MA 01103 Ashfield Deerfield Heath Monson Russell Washington Phone:413-784-1100 Becket Easthampton Hinsdale Mount Washington Sandisfield Wendell Belchertown East Longmeadow Holland New Ashford Savoy Westfield Fax:413-784-1149 Bernardston Egremont - Holyoke New Marlborough Sheffield Westhampton Blandford Erving Huntington New Salem Shelburne West Springfield Brimfield Florida Lanesborough North Adams Shutesbury West Stockbridge Buckland Gill Lee Northampton Southampton Whately Charlemont Goshen Lenox Northfield South Hadley Wilbraham Cheshire Granby Leverelt Orange Southwick Williamsburg Chester Granville Leyden Otis Springfield Williamstown Chesterfield Great Barrington Longmeadow Palmer Stockbridge Windsor Chicopee Greenfield Ludlow Pelham Sunderland Worthington Clarksburg Hadley Middlefield Peru Tolland DEP Central Region Acton Charlton Hopkinton Millbury Rutland Uxbridge 627 Main Street Ashburnham Clinton Hubbardslon Millville Shirley Warren Ashby Douglas Hudson New Braintree Shrewsbury. Webster Worcester,MA 01605 Athol Dudley Holliston Northborough Southborough Westborough Phone:508-792-7650 Auburn Dunstable Lancater Northbridge Southbridge West Boylston Fax:508 792-7621 Ayer East Brookfield Leicester North Brookfield Spencer West Brookfield Barre Fitchburg Leominster Oakham Sterling Westford TDD:508-767-2788 Bellingham Gardner Littleton Oxford Stow Westminster j Berlin Grafton Lunenburg Paxton Sturbridge Winchendon Blackstone Groton Marlborough Pepperell Sutton Worcester Bolton Harvard Maynard Petersham Templeton Boxborough Hardwick Medway Phillipston Townsend Boylston Holden Mendon Princeton Tyngsborough Brookfield Hopedale Milford Royalston Upton DEP Southeast Region Abington Dartmouth Freetown Mattapoisett Provincelown Tisbury 20 Riverside Drive Acushnet Dennis Gay Head Middleborough Raynham Truro Attleboro Dighton Gosnold Nantucket Rehoboth Wareham Lakeville,MA 02347 Avon Duxbury Halifax NewBedford Rochester Wellfleet Phone:508-946-2700 Barnstable Eastham Hanover North Attleborough Rockland West Bridgewater j Berkley East Bridgewater Hanson Norton Sandwich Westport Fax:508-947-6557 � Bourne Easton Harwich Norwell Scituate West Tisbury TDD:508-946-2795 Brewster Edgartown Kingston Oak Bluffs Seekonk Whitman Bridgewater Fairhaven Lakeville Orleans Sharon Wrentham Brockton Fall River Mansfield Pembroke Somerset Yarmouth Carver Falmouth Marion Plainville Stoughton j Chatham Foxborough Marshfield Plymouth Swansea Chilmark Franklin Mashpee Plympton Taunton i DEP Northeast Region Amesbury Chelmsford Hingham Merrimac Quincy Wakefield 205 Lowell Street . Andover Chelsea Holbrook Methuen Randolph Walpole Arlington Cohasset Hull Middleton Reading Waltham Wilmington,MA 01887 Ashland Concord Ipswich Millis Revere Watertown Phone:978-661-7600 Bedford Danvers Lawrence Milton Rockport Wayland Fax: 978-661-7615 Belmont Dedham Lexington Nahant Rowley Wellesley Beverly Dover Lincoln Natick Salem Wenham TDD:978-661-7679 Billerica Dracut Lowell Needham Salisbury West Newbury Boston Essex Lynn Newbury Saugus Weston Boxford Everett Lynnfield Newburyport Sherbom Westwood Braintree Framingham Malden Newton Somerville Weymouth Brookline Georgetown Manchester-By-The-Sea Norfolk Stoneham Wilmington Burlington Gloucester Marblehead North Andover Sudbury Winchester Cambridge Groveland Medfield North Reading Swampscott Winthrop Canton. Hamilton Medford Norwood Tewksbury Woburn Carlisle Haverhill Melrose- Peabody Topsfield wpaform8b.doc•Appendix A•rev.10/20/03 Page 1 of F Date. . '. . . Of NORTH try o? 1 TOWN OF NORTH ANDOVER f F " PERMIT FOR GAS INSTALLATION �9 SACMUI - fl This certifies that . . . : . . . :` . . . . . . .. . . . . . . . . . has permission for gas installation . . .. . . . . . . . . . . . . . . . . . . in the buildings of . .. . . ` ... .:R at .i , North Andover, Mass. Fee. `. .. . . Lic. No.. . . . . . . .. . . . . . . . . . GAS INSPECTOR f Check 4 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) - — NORTH ANDOVER ,Mass. Date 3/18 2009 Permit# r = l' Building Location 53 OLD CART WAY Owner's Name KRISTEN GUTHRIE Owner Tel# 978 975 0459 Type of Occupancy RESIDENTIAL New F_1 Renovation❑ Replacement w] Plan Submitted: Ye[]No❑ FIXTURES cocktol 4, C4 30.50 Cna a o x x U �, x H H >, z H aW w z O ¢ a a 0 o Z F Mw ¢ x ° n a a > ¢ z �Z Vj 0 Q WQ z w z x x `� o > o W' a w .aa SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR N Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter DON HOWE INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes l ✓ I No ❑ If you have c ecked�,please indicate the type coverage by checking the appropriate box. A liability insurance policy ✓� Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued ferNs applic 'on will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General La By Type of License: — ••umber Signature Lic nsed Plumber or Gas Fitter Title as fitter Z_ •-Master License Number City/Town •-Journeyman APPROVED(OFFICE USE ONLY) O "OR7M 1 c o � ...ram. • °acHusfi CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number Date %/-7 - 6' THIS CERTIFIES THAT THE BUILDING LOCATED ON )d9,4 C)IC 04 tV 4 MAY BE OCCUPIED AS 5/,V /C- I-A 114' / �'� �ti IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE UILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. -7 ,000M 5, 3-58 Amsi oZ 6Ydi/ v.v D C=K � K" I IS 4'" CERTIFICATE ISSUED TO � &I Ili uAti ADDRESS a 1CP CAR-t W,4 Y C ! Building Inspector i NORTH Town O L over 0 No. 0 C L is CO �1 E dover, Mass. RA T E D F? Ci S SE BOARD OF HEALTH Food/Kitchen PERMIT T Septic Systern441..%, BUILDING INSPECTOR THISCERTIFIES THAT .. . ..... ........................................................ ............................................... ............................. Foundation./*I*(C'__ has permission to erect................. buildings on -ho..?A )v S3 Oh ICARr WKI 'of himney • a 8A*... k +3� Roughirit&?, [)-if to be occupied as... ..................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Afteratiop and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. �,f rtl_ 7 vo, ve, (9 /0 PERMIT EXPIRES IN 6 MONTHS ft ',�ELECTRIC EC 7 UNLESS CONSTRUCTION STARTS • '7 7 771,� ........ ......................................................................... BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street Smoke D) No. S SEE REVERSE SIDE et.. Town of North Andover o& tkORpH q ttLeo ib 4 Building Department o 27 Charles Street 0 North Andover, Massachusetts 01845 -V (978) 688-9545 Fax (978) 688-9542 ACHUS�� APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS S3 o`l C,/-�� T WAY LOT NUMBER 7A ')4 DATE REQUEST FILED OCYOSW /710 Z001 l DATE READY FOR INSPECTION � � Z o 0 l I FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED j ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-INSPECTION FEE OF TWENTY-FIVE($25.)DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE OFFICIAL USE ONLY ROUTING CONSERVATION j 1114 DATE PLANNING r DATE �d J D.P.W. —WATER ME DATE D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PT THE INSPECTION RE STD TE. 1 GN TURF/ ORIZATION Date.'—o'�: .�:�. .�. �. . ... .. pf.NORTH TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION 9SSAtHUS This certifies that . f. . . c-. / . . . . . . . . . . . . . . has permission for gas installation . . .A . . . . ... .`. . . . . . . in the buildings of . . .5 . . . . . . . . . . . . . . . . . . . . . . . . . . at !' , . . . ./,?',Y. .,1 North Andover, Mass. Fee. .. . . Lic. No.. dASINSPECTOR Check#-k- Cc3 'MASSACHUSETTS UNIFORM APPLICATON FOR PERM TO DO GAS FITTING (Type or print) Date f/f/a d3� Zfio/ NORTH ANDOVER,MASSACHUSETTS Building Locations Cs- 3 C�i r Ltl& Permit# Amount$ Owner's Name New Renovation ❑ Replacement P Submitted p ❑ ❑ x � a ° o z ° W ca H w a a , W4 d z o x > w d PQ SUB-BASEM ENT B A S E M ENT IST. FLOOR ..N D. FLOOR IR D. FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH. FLOOR 1 14fil (Print or type) // CAk one: Certificate Installing Company Named/Glr //�G •�c� ❑ Co Address 34 `� ❑ Partner. Business Telephone G} 7d' iL —7 3 3 Firm/Co. Name of Licensed Plumber or Gas Fitter �/�j J.< Gr�� S2 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No❑ If you have checked}_es,please indicate the type coverage by checking the appropriate box. Liability insurance policy IT' Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Signature of Licensed Plumber Qr Gas Fitter Title ❑ Plumber City/Town ❑ Gas Fitter LicenseNumber ❑'Master APPROVED(OFFICE USE ONLY) ❑ Journeyman Location n a� Y7/� � `� 3 0�� No. //4 Date NaRT� TOWN OF NORTH ANDOVER R ` Certificate of Occupancy $ • i i 4 A Building/Frame Permit Fee $ S�1C14 U5 Foundation Permit Fee $ 1 00( Other Permit Fee $ i TOTAL $ /S �-^- Check # W 1 4 " S 5 Building Inspector m TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING . .:: ^:i'.^ � �i r'1 Y•'�� a7.TV�i1�, � 0�1 v,;n4 1, —� t ix, i>lay$ {'r } BUILDING PERMIT NUMBER. DATE ISSUED: ic SIGNATURE: Building Commissioner/I for of Buildings Date z SECTION I-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 53 OLD CAa WAY o7 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Z .SINGLE ram)t y Y7 3 y z iso Zoning District Proposed Use Lot Area(sb Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Re red Provided 30 30 30 30 3e 30 1.7 Water StlPply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private 0 Zone Outside Flood Zone Municipal 0 On Site Disposal System SECTION 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT 2.1 Owner of Record To l4r/ f KRIII av SXVV*( 113 1Q.SARI) ST (a&)& MA el 90 1 NP, Name(Print Address for Service: yj q )#Zt&;7 (701) �3�+9i'�3 6 Sign Telephcrne O 2.2 Owner of Recordy_ Name Print Address for Service: M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 00yyz 0 11 3 A` (AI !—� ST " ,/1_ , M/t 0 1 6I License Number 1 ✓ yC [JVC� ✓�f llJ Address /' r l Z p D 791 93s-111 Expiration D o ll _ Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ URT T JAL v- (SVIVIAAL1 a 2 y Company Name /) iM Z� f f �6/lv,/I_ , MA glool Registration Number Address J J� JJ�t-L J D /�►E/ Z Lo r7 �6 ��,��, �� " Expiration D e Signature Telephone I i SECTION 4-WORKERS COMPENSATION(M.G.L. C 1.52 § 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. Si ned affidavit Attached Yes...... No.......0 SECTION 5 Descriion of Proposed Work check au applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: NEw Gam/f T►21 L I blv �F"A S I rvGL�' l�✓>er►'� y` �/ "LL>N�, (�,ff A7T A(A f'� $v(L�)h/G d° f SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be USEpmn �UI : T Completed b permit applicant _ ' I. Building (a) Building Permit Fee Multiplier (� ' 2 Electrical (b) Estimated Total Cost of 016-0 Construction 7 � 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC J� (� 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATIO TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -F I, yo- LW J S✓Wt�/ _ as Owner/Authorized Agent of subject property Hereby authorize / Llk>'��7 a On"" to act on My behalf,in all rs lativ totrauthonze by this building permit application. Si nahue of Date I?i Z v SECTION 7byN A RAGENT DECLARATION 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 J-0 uN 0 Print Name AV 4 �. Signature of O A ei Date NO. OF STOMYS SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2ND 3RD 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 i L 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. .......................................................................q..�/... APPLICANT JAL K 4 W 3Tt'V ,SOLL'L'AV PHONE ASSESSORS MAP NUMBER io-7 B /1,- 8 Y LOT NUMBER 8 SUBDIVISION LOT NUMBER 1A STREET ow 64K7 W 4 Y STREET NUMBER 53 ........................................... ...........................,..... OFFICIAL USE NLY RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED 2 6 CO SERVATION ADMINISTRATOR / DATE REJECTED COMMENTSpry (o/,)`Yc,(j(fTI,) DATE APPROVED /TO PLANNER '• DATE REJECTED COMM EN TS ! C� C DQ�4 0 u DATE APPROVED /. 7FOODNSPECTOR-HEALTH DATE REJECTED _ DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT 2 - Z Z- ��9t� DATE APPROVED FIRE DEPIARTmRIT DATE REJECTED CONIIvIENTS RECEIVED BY BUILDING INSPECTOR DATE E C Elea O V RnwD Lj hLD B ILO DEPT. A Building Value Calculation - for lro a at..... LOT#7-A e i- - .. Room Length Width Sq.Ft. Cost per Sq.Ft. Total Cost Kitchen 25 14 350.00 65 $ 22,750.00 Living Room 16 14 224.00 65 $ 14,560.00 Dining Room 14 14 196.00 65 $ 12,740.00 Family Room 24 15 360.00 65 $ 23,400.00 Study 9 6.5 58.50 65 $ 3,802.50 Laundry 9 6 54.00 65 $ 3,510.00 Garage 24 24 576.00 35 $ 20,160.00 Entry 14 14 196.00 65 $ 12,740.00 Basement Finished - 65 $ - Deck - 10 $ - Screened Porch - 35 $ - Breakfast Nook - 65 $ - Bedroom 1 24 15 360.00 65 $ 23,400.00 Bedroom 2 16.5 10.5 173.25 65 $ 11,261.25 Bedroom 3 16.5 13.5 222.75 65 $ 14,478.75 Bedroom 4 16 11.5 184.00 65 $ 11,960.00 Bedroom 5 14 14 196.00 65 $ 12,740.00 Bathroom 1 14 9.5 133.00 65 $ 8,645.00 Bathroom 2 9 6.5 58.50 65 $ 3,802.50 Bathroom 3 - 65 $ - Bathroom 4 - 65 $ - Bathroom 5 - 65 $ - IRWIN 1,14.1 L 1 GROWTH MANAGEMENT BYLAW EXEMPTION STATEMENT TOWN OF NORTH ANDOVERBUILDING DEPARTMENT This form shall be used to assist the Building Department in their determination of exemption under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The applicant shall provide all of the necessary information as requested below. 3'b9N sKA%15T ry 5()LL1yAN 53 Opp CART WAY io7 S 8$ Permit Applicant Property address Map/ cel (791) ?35 1/V3 —X Applicant's Phone Number Single Family Two Family I the undersigned applicant for the above property attest that the attached building permk 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 ofthe 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 given the environmental conditions of the tract,with the surplus land equal to at least ter buildable acres and permanently designated as open space or farmland.The land to be preserved shall be protected$om 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 one time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit on the parcel. Ibis 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 TIIE ATTACHED BUILDING PERMIT IS ALL WED AN EXEMPTION AS CITED ABOVE. FURTHER I UNDERST D AT THE SUBMITTAL OF MISLEADING OR INACCURATE INFORMATION OR THE CHECKING O F OFA O EXEMPTION WHICH DOES NOT COMPLY,WHETHER DONE TO MY KNOWLEDGE OR NOT IS GR F U SAL BY THE BUILDING DEPARTMENT TO ISSUE A BUILDIN PE MIT. � 8 01 APPLIC SIGNATURE DATE THIS FIRM TO BE ATTACHED TO THE BUILDING PERMIT APPLICATION MORTH Town Of North Andover oE «.o ,.�►o Community Development & Services William J. Scott p O 27 Charles Street Director ----, North Andover, Massachusetts 01845 (978) 688 9531 �9SSACHUSE4 Fax 978-688-9542 ' Board of Appeals July 19, 2000 (978)688-9541 Building Thomas Neve Department Neve and Associates (978) 688-9545 447 Old Boston Road Topsfield, MA 01983 Conservation Department (978) 688-9530 Re: Lot 7A Old Cart Way Health Department Dear Thomas: (978)688-9540 This is to inform you that the septic system plans dated 6/1/00 for the site Public Health referenced above has been approved for a maximum of nine (9) rooms. Nurse (978) 688-9543 If you have any questions, please do not hesitate to call the Board of Health Planning Office at 978-688-9540. Department (978) 688-9535 Sincerely, Sandra Starr, R.S., C.H.O. Health Director S S/smc cc: Maus File i The Commonwealth of Massachusetts Department of Industrial Accidents { Office of/iilreS&ffJ gins 600 Washington Street --- - .y Boston,Mass. 02111 Workers' Com ensation Insurance Affida,61 name' 1 location- r / t 4 sAl /t N, city ti <� /� phone ❑ I am a homeowner performing all work myself. �` I am a sole pro�rictor and have no one working in any ca acity ❑ I am an employer providing workers' compensation for my employees working on this job. _ company name: i - ._- _, j address:. -. cftti phone#:. _. insurance co.: Rolicv# "; ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers compensation polices: company name: .:..:. address. ..........:.:.: :: city phone#:<: insurance co. . / :campany`name: ` - address. ctty a phone#: .. :.: _:. .... _::. ... ... _.... _..... ...... ._._ ... __...... 4n�urance co:-: . olicv#..>. Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of crhminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 1100.08 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 certify under the pains and penalties of perjury that the information provided above is true and correct: Signature_�G✓1` � � Date Print namei �� <d,�.�st-r Phone# Mr— M-(2 ,$0 -(9 .official use only do not write in this area to be completed by city or town official S' city or town: permit/license rt 0 Building Department ❑Licensing Board ❑check if inunediate response is required ❑Selectmen's Ofnce K ❑health Department £ tooted person: phone tt; ❑Other )-w Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire, exTress 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 section 25 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,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 in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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 peimit/license number which will be used as a reference number. The affidavits may be returned to . . the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 of Invest1gations 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 nhone#- (617) 727-4900 ext_ 406. 409 or 375 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 004429 Birthdate: 09/11/1944 Expires: 09/11/2001 Tr.no: 5217 Restricted To: 00 ROBERTJ DELUCA _ 193 REAR SALEM STS WOBURN, MA 01801 Administrator f NOME IMPROVEMENT CONTRACTOR Registration: 102482 P Expiration: 112102 Type: Individual ROBERT J. DELUCA Robert DeLuca 193 Rear Salem Street AOMINISTR.4roR Noburn MA 01801 i 4 } I I MAScheck COMPLIANCE REPORT I I Massachusetts Energy Code I Permit # I MAScheck Software Version 2.01 Release 3 I I I I Checked by/Date I I I TITLE: PLAN NO. 2114 CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 10-20-2000 DATE OF PLANS: 10-20-00 PROJECT INFORMATION: COLONIAL HOUSE COMPANY INFORMATION: BRUNO ASSOC. 28 BERKELEY ROAD N. ANDOVER, MA 01845 COMPLIANCE: Passes Maximum UA = 545 Your Home = 426 Area or Cavity Cont. Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 1416 30.0 0.0 50 WALLS: Wood Frame; 16" O.C. 2592 13.0 0.0 213 BSMT: Conc. 8.0' ht/7.0' bg/8.0' insul 1416 19.0 0.0 64 GLAZING: Windows or Doors 312 0.300 94 DOORS 18 0.300 5 HVAC EQUIPMENT: Furnace, 87.0 AFUE ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer Date TITLE: PLAN NO. 2114 MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.01 Release 3 DATE: 10-20-2000 Bldg. 1 Dept. 1 Use I I I CEILINGS: [ ] I 1. R-30 I Comments/Location I I WALLS: [ ] I 1. Wood Frame, 16" O.C., R-13 I Comments/Location I I BASEMENT WALLS: [ ] I 1. Conc. 8.0' ht/7.0' bg/8.0' insul, R-19 interior cavity I Comments/Location I I WINDOWS AND GLASS DOORS: [ ] I 1. U-value: 0.3 For windows without labeled U-values, describe features: I # Panes Frame Type Thermal Break? [ ] Yes [ ] No I Comments/Location I I DOORS: [ ] I 1. U-value: 0.3 I Comments/Location I I HVAC EQUIPMENT: [ ] I 1. Furnace, 87.0 AFUE or higher I Make and Model Number I AIR LEAKAGE: [ ] I Joints, penetrations, and all other such openings in the building I envelope that are sources of air leakage must be sealed. When I installed in the building envelope, recessed lighting fixtures I shall meet one of the following requirements: I 1. Type IC rated, manufactured with no penetrations between the I inside of the recessed fixture and ceiling cavity and sealed or I gasketed to prevent air leakage into the unconditioned space. I 2. Type IC rated, in accordance with Standard ASTM E 283, with no I more than 2.0 cfm (0.944 L/s) air movement from the the I conditioned space to the ceiling cavity. The lighting fixture I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure I difference and shall be labeled. I VAPOR RETARDER: [ ] I Required on the warm-in-winter side of all non-vented framed I ceilings, walls, and floors. I I MATERIALS IDENTIFICATION: [ ] I Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating I and cooling equipment and service water heating equipment must be 1 I provided. Insulation R-values, glazing U-values, and heating I equipment efficiency must be clearly marked on the building plans or specifications. I DUCT INSULATION: [ ] I Ducts shall be insulated per Table J4.4.7.1. I I DUCT CONSTRUCTION: [ ] I All accessible joints, seams, and connections of supply and return I ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed I using mastic and fibrous backing tape installed according to the I manufacturer's installation instructions. Mesh tape may be I omitted where gaps are less than 1/8 inch. Duct tape is not I permitted. The HVAC system must provide a means for balancing I air and water systems. I I TEMPERATURE CONTROLS: [ ] I Thermostats are required for each separate HVAC system. A manual I or automatic means to partially restrict or shut off the heating I and/or cooling input to each zone or floor shall be provided. I I HVAC EQUIPMENT SIZING: [ ] I Rated output capacity of the heating/cooling system is I not greater than 125% of the design load as specified I in Sections 780CMR 1310 and J4.4. I I SWIMMING POOLS: [ l I All heated swimming pools must have an on/off heater switch and I require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. I I HVAC PIPING INSULATION: [ ] HVAC piping conveying fluids above 120 F or chilled fluids I below 55 F must be insulated to the following levels (in. ) : I I PIPE SIZES (in. ) HEATING SYSTEMS: TEMP (F) 2" RUNOUTS 0-1" 1.25-2" 2.5-4" I Low pressure/temp. 201-250 1.0 1.5 1.5 2.0 I Low temperature 120-200 0.5 1.0 1.0 1.5 Steam condensate any 1.0 1.0 1.5 2.0 I COOLING SYSTEMS: I Chilled water or 40-55 0.5 0.5 0.75 1.0 I refrigerant below 40 1.0 1.0 1.5 1.5 I I CIRCULATING HOT WATER SYSTEMS: [ ] I Insulate circulating hot water pipes to the following levels (in. ) : I I PIPE SIZES (in. ) I NON-CIRCULATING I CIRCULATING MAINS & RUNOUTS HEATED WATER TEMP (F) : RUNOUTS 0-1" I 0-1.25" 1.5-2.0" 2.0+" I 170-180 0.5 [ 1.0 1.5 2.0 I 140-160 0.5 I 0.5 1.0 1.5 I 100-130 0.5 I 0.5 0.5 1.0 I \ ----NOTES TO FIELD (Building Department Use Only)------------------------- i f ti TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET, 01845 J.WILLIAM HMURCIAK, P.E. Telephone(978)685-085G DIRECTOR Fax(978)688-9573 rIORTIy 20EtLEO , 0 0 T o4P p♦PPS.(P7 . 9SSACHU5ES I DRIVEWAY PERMIT DATE �� ZL Z LOCATION 55 7,q BUILDER phone OWNER (c' phoned _ 9�S THE NORTH ANDOVER SUPERINTENDENT OF OPERATIONS MUST BE NOTIFIED OF THE GRADE AND SETBACK FROM STREET . CALL THE SUPERINTENDENT'S OFFICE BEFORE FINISH GRADING AND SURFACING FOR APPROVAL OF SUCH ENTRY. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. I i L-"9&>1 �� Q 1038 APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. 2,, L– 19— (� Application by the undersigned is hereby made to connect with the town water main in r'� �r!� � � Street, subject to the rules and regulations of the Division of Public Works. 1 01,14 �� l f/ 1 The premises are known as No. 01, .{ �Cl (�VG�. Street or subdivision lot no 74 35 - l Az_ 5 rk- C C l Owner Address Contractor Address pplicant's +nature jl r ` PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to �:� '1 1✓ '% , G1 C'i ' V to make a connection with the water main at Street subject to the rules and regulations of the Division of Public Works. / f— .-Board Board of l Public Works i ii I y 7/Inspected by ,> Date See back for rules and regulations \.}', \;,�-�'; �'tl)t� !/� .%'L(,- 1. `�> � V/%�G /f� l•��`/{C, =( '/�117 �Gf ,�'J`C:L� 4 DPW 304 T TOWN OF NORTH ANDOVER n RE_CE_ S`S'�CHUSEt IPT This certifies that ��C 1� ... .. ................��... � S! t ..I—% K �i. has paid..... .... ....................I..r....�S� ''Ir for... °' �� ^}/ .. l -r— -7 G !0r /l Received by ....................... r. t .�.... .......... Department............... . WHITE: Appl;cant CANARY:Department PINK:Treasurer I 30'-0" 16'-0" 14'-0" - BOILERSTORAGE ROOM 0 I co N BATHROOM L-6 28' GARAGE EXERCISE ROOM co LAUNDRY CLOSET 3'-0" o� t 2,-6" ATTACHMENT SHOWING BASEMENT SCALE: 1 /4"=l' QRTH Town o Andover 0 lit No ndover, Mass., y—o't AGO/ 2COCMICHEWICK ADRATED PP��.(� SSA Ht15� I T FOR EXCAVATION AND FOUNDATION THIS CERTIFIES THAT ... ......�WRAV................................................ -1 CIA Wr Wia has permission to excavate and pour foundation at .AQ .. .. for the purpose of....I Room� �/� ,�� all..1 ! 0/0 �!V .............. ............. ..... .................. .... The person accepting this permit must return to the office of the Building Inspector a certified plot plan show of building thereon before Foundation will be inspected. 'O J7 is #0 a a VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS The holder of this Foundation Permit proceeds at own risk and without UNLESS CONSTRUCTION STARTS assurance that a permit for entire building structure will be granted. s BLDG. PERMIT FES� �3 � ' � • LESS FDA FEE d' DUE FRAME PERMIT$ /2 OD,` BUILDING INSPECTOR NORTH F � Town of dover No. O COC o lover, Mass., MIfL ORATED P '0�S S GG 5 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT...'.. .. I .. .. r�. ' ...,.,sto//I VAN BUILDING INSPECTOR .. . .................................. ................... Foundation has permission to erect...................�.................. buildings on .. . .�A...�.s'.3.....%..........C�oRway Rough R." q • .. ava� r &VAysi t0 be occupied as... I...................... ..�.......�................ ........................................... ..................... himney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Afteratio and Construction of Buildings in the Town of North Andover. I'7 Q 0849 �OZOO PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR e Rough .......... ... . .... . .............................................................................. Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises - Do Not Remove RoughFinal 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. .... .3 i _ 0 Date....... . ... . ...�� N°RTM TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACHUS� C This certifies that ..:.... ......t..k.:'!.......................................................... has permission to perform ....... f� wiring in the building of ....:......... #u atS` 77 Vl ci ;/ `.4/North Andover, assn Fee; �r.� ... Lic.No /..,y �....... �f...!.a �. !' . . ` LECTRICALINSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer P I The Commonwealth of Massachusetts OFFICE USE ONLY y Department of Public Safety Permit # Board of Fire Prevention Regulations Fee Pd. 527 CMR 12:00 Check # APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with Mass. Electrical Code (Please print in ink or type all information) DATE: -±UQe- Y d] N 014 DW&te- TOWN OF TO THE INSPECTOR OF WIRES: The undersigned applies for a permit to perform the electrical work described below: Location(Street and Number) ['�,� ��A QJr tN4y S3 Owner or Tenant ,�" p�j /✓e-1-1 cpt OCA aw LG �»�ruc�'jC)1d Owners Address ClP+A<Z- �3t- Is this permit in conjunction with a building permit? V�ES' NO Purpose of Building NeW {.h)yy}.Q_ Utility Authorization�C53 Existing Service AMPS VOLTS OVERHEAD UNDRGRND #Meters New, Service AMPS /c �OLTS OVERHEAD UNDRGRND &e- #Meters_ Number of Feeders and Ampacity Please list all work to be done here: n pwar .r� INSURANCE COVERAGE: Pursuant to the requirements of Mass. General Laws, I have a current Liability Insuranc o cy including Completed Operations Coverage or its substantial a lent. Yes No I have submitted valid proof of same to fice. a No If you have checked YES, please indicate the pe of co erage b eking the appropriate box. eIlSURANCE: BOND OTHER Please Specify rrp (7Expiration Date ) Estimated Value of Electrical Work $`2 =.0d1 Work to Start Inspection Date Requested:Rough� /U^��Final Signed under the penalties of perjury: wYU. CV1Q (,L FIRM NAMELIC.# LICENSEE A ,1;Z&DOLATGNATURE AAAJ LIC.# 4 /6W'-s ADDRESS BUS.TEL# `1 3 3 y ALT. TEL#9-79 g' 1 I931 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Tel.# (Signature of Owner) Location No. �+ Date f NORTq TOWN OF NORTH ANDOVER °c J6. A i Certificate of Occupancy $ s i �'�a",•' EBuilding/Frame Permit Fee $ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # Building Inspector Date ,i N° TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING s � •'a ,SSACMUS� / This certifies that . . . r• • .�' �•� . . . . . . . . . . . . . . . . has permission to perform . . . . . .ke-cx. . . . °!.` . . . . . . . . . . . . . . plumbing in the buildings of . . . .!9. . . . . . . . . . • • • • . at . . .-5* * 3. . .�-�.��. ?�. t-< `�.`/. . , North Andover, Mass. Fee. �LJ `. .Lic. No.. . . . . . . . .C:... ".-Y---" . . . . . PLAUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS BuildingLocation -3 �✓ �lc Gl/ Owners Name Su ��W-1 Date Permit# Amount So Type of Occupancyj�y/ New Renovation Replacement Plans Submitted Yes No El FIXTURES F a, w w A A Q ]ST KOM / / AD ROCK 4IF3 kIOQt 5TH mm 6IH FI�OQ2 7m mm SIH KOM (Print or type) �� `lr �i��/f� � _Check one: Certificate Installing Company Nam\e /,(�i J �r �Qj�J/lam// Corp. Address 3d CAeal"6-je f.I2r`r. � Partner. Business Telephone 7 - - 3 Fimi/Co. - Name of.Licensed Plumber C t/( Insurance Coverage: Indicate the tyrfe of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ElBondu Insurance Waiver. I,the undersigned,have been made aware that the licensee ofthis application does not have any one of the above three insurance. Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach'State P mb - =; IChZpte '42 of the General Laws. By: ign ot Llcens e Title r Type of Plumbing License /QS� City/Town icease um er Master Joumeyman n APPROVED(OFFICE USE ONLY LJ I I I