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Miscellaneous - 60 PATTON LANE 4/30/2018
60 PATTON LANE 210/106.A-0166-0000.0 Date... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 88�cMuss . This certifies that ............/ .. ...:.......!" 71..<.........::......................... has permission to perform ...........i-<.i Mkr,.rte..................... wrongin the building of........... ........................................................................ ;at ........�?r�...:� �`� � !.......L:- ..................................North Andover,Mass. Fee.. Lic.No. n.1' ,/00, `:.. .... EICECTRICAL INSPECTOR/- Check# (/�) 12201 . . COi7=nweaa 0/va-mack aadef Official Use Only c� Permit No._ e(JePaPtmerct o��i�e�ePuice� Occupancy and Fee Checked To BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07]- (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(h EC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFOMIIIATION) Date..Ild s,j q City or Town of: ANNOW NmW AaV1G) VL To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street Number) 6o PA} (.,Awl_ Owner or Tenant x�`��q } 5C►p1*,� Telephone No. 51 Q` `72AP 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❑ No.of Meters Number of Feeders and Ampacity Location andNatureof Proposed Electrical Work: i` fdkG` L*d Old WO(LK— _Q.Q.YWO� Com letion of the followin table may be tiYaived 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. Above Ej In- No.of Emergency Lighting No.of Luminaires Swimming Pool rnd. gind. Battery Units ' No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and Initiating Devices �• No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Disposers Heat pump I i RMhm r...Tons K�'_...... No.of Self-Contained Totals: Detection/Alertin Devices No.of Dishwashers ( Sp g ace/Area Beating KW Local❑ Municipal ElOther Connection No.of pryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.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: -�/ e p Attach additional detail if desired,or as re luired by the Inspector of Wires. Estimated Value of Electrical Work: c� O• (When required by municipal policy.) - Work to Start: e ;�,$' 1 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove.>gt is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE:. INSURANCE V 13OND ❑ OTHER ❑ (Specify:) r I cert,under thepains andpenalties ofperjury,that the information on this application is true and-complete. ' FIRM NAME: LIC.NO.:10/a'% Licensee:' Signaturey � "� LIC.NO.:(O L (Ifnpplicable,enter "exein.the 1' n e umber line.) �T Bus.Tel.No.: 3Q Address: t" Alt.Tel.No.: 12.2_ *Per M.G.L.c. 147,s.57-61,security work requires epartment oPublic Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does plot have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERWT FEE:$ Signature Telephone No: , 4 s q ra r 4 I V i. 1 � t S � t• •�Y ... 1rt�.4.4. t A' S I' t f . .. � C • l . � ! t f a `Core"401*vUEALTIIOF MAS51'Ct:t1 I T1 } 77 7- ELECTRICIANS AS A REG JOURNEYMAN ELECTRICIAN ISSUES THE ABOVE LPrFNSE TO: JAMESTIGREGORIO 65- BEV'LEVUE-, ' AV WINTHROPMA 02152`=220 10156 _B _D7/31/16' 875069 l i i 1 Date I ..��`�....... 10434 TOWN OF NORTH ANDOVER * PERMIT FOR PLUMBING � $3ACMU5� 1� Thiscertifies that....:............:.................................... .....................................nn..................... has permission to perform.....� .....................:...!- ` �C plumbing in the buildings of........ .�'.z-• .. .. .............:................................................. j at.... ..... Q...........^�......1 .!J.,......................:......... North Andover, Mass. �? 2.3�11Z- M Feeb.].............Lic. No. ..................... ....... .................:............................................. -r PLUMBING INSPECTOR Check# U MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK tot 0 ' CITY ` MA DATE PERMIT# JOBSITE ADDRESSJ= OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES E11 NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ( i _ 1 ___! [ _! l _- i _—! CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I J -.-.._._{ �._I _._.! _.._._.! __.___! _J ____1 ._...___I _._.._( .—i ! __.f DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER ._I ._ 1 _---_._-� -__.__I __. S _ ___-.._..1 FLOOR/AREA DRAIN 1 1 _-__f _.___i INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK I l ( f _ ._. -I __j TOILET URINAL WASHING MACHINE CONNECTION WA ER HEATER ALL TYPES I 1 _ f ► _� __ __! _.._! _ l a r WATER PIPING I . 't f _._ _a _I -_ __ OTHER I I --_._._._1 .___! -I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .___ NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND �1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F-1AGENT0SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge �- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent p�o vision of he — Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L, _ LIQENSE# . > SIGNATURE MPOI JP4 CORPORATION !1#PARTNERSHIP F# LLC COMPANY NAME�'M1[ ( �� ADDRESS CITY �C I STATE ZIP _Q l � TEL FAX _ f CELL ._ . °._. tZ�l EMAIL _......__...__._ .._._..__._. _i ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTWONAOTES Yes No / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES r The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations kvi 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ^ Please Print Legibly Name(Business/OrganivatiorAndividual): )�W\r,3 Address: City/State/Zip: C55 e,X )-AA QlcMRi Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.ID I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction e oyees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.# E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, workers'comp.insurance. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its aired. officers have exercised their 1011 Electrical repairs or additions required.]] 3. I am a homeowner doing all work right tion of ht exemption per MGL 11.[J Plumbing repairs or additions ❑ g P myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]f employees.[No workers' 13.0 Other comp.insurance required.] *.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 ai-e doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. l Insurance Company Name:. P51�e 1`�\I 1/JS�--fin CCC', q ec t 'C-5 S Policy#or Self-ins.Lie. Expiration Date: Job Site Address: (,�D City/State/Zip: Apc d c� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Simature: Date: t- Phone#• t: 75U-614 614 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#: l 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 he. 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 futureermits or licenses.p s s. 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, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidoats Office of InVestigations 600 Washington.Street Boston}MA.02111 TO.#617-727-4900 ext 406 or 1-877 MASSAFE Revised 5-26-05 Fax#617-727.7749 www a=ss,goVaa COMMONWEALTH OF MASSACHUSETTS ASFITTER LICENSED AS A JOURNEYMAN: PLUMB ISSUES.THE ABOVE LICENSE TO: - KEVIN .0 MACDONALD 2 `'EVANSWAYE ESSEX : ?"' - -_MA 01929.-1160 23412 05/01/14 143133 . , Date...7.......5. .......� ..... HORTI� "° TOWN OF NORTH ANDOVER OL p PERMIT FOR WIRING ,SSACH This certifies that .......... `0// . has permission to perform1 ..! ... � � .� G .. . .. ............ ...... . . ....�./....ti.../..1..-r Xwiring in the building of.....C./r c ../t'? ................. at...1�.1.... `...........'A.. ................... .North And7�.. Fee...... ......... Lic.No..Z✓.2!J........ ... ...... LECMCAL INSPECMR Check # �I Official Use only DI1t1li�lJltlDQ L O a3daG LlL•�D� Y cc�� cc77 PermitNo. V vUoparintonf D�.�`ira saran d ' Occupancy and Fee Checked BOARD ------- A OF FIRE PREVENTION REGULATIONS ev. a r7 . � 1 (leave bland APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance wish the Massachusetts Electrical Code C),S? CMR 12.OD (PLEr1SE PRINT 17V B OR TYP r W OR11 MITION� Date: City or Town af: a To the Insp 6ir of ivirm i By this application the undersigned give notice of s or her intention to perform the electrical work described below. Location(Street,&Number) 0Yt ay,-f Owner or Tenant Telephone No. Owner's Address (� Is this permit in conjunction witil a builp g permJit? Yes ❑ No (Chack Appropriate Box) Purpose of Bu€)ding �h ! y Utility Authorization No. Existing Service Amps ! Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Coni letibn ofthe folloivin table may be valved bp the 1) ecror al lhires. No.of Recessed Luminaires No.of Ceil,-Susp.(Paddle)Fans No.of Total Transformers ICVA i No,of Luminaire Outlets No.of Hat Tubs Generators ICVA. No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mcrgency ig ing rad. d. Bnt#eV Unfts No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No,of Switches No.of Gas Burners o.of Detection an Initfaiin Devices No. of Ran es No.of Air Cond. Total g � Tons � No.of Alerting DevIees No.of Waste Disposers HentPurnp Number TDn 1ICW No.of.elf- ontained Totals: Detection/Alerting Devices No.of Dishwashers Space/Aren Heating 1CW Local❑ Municipal ❑ Other Connections No.of Dryers Senting Appliances I13V Security Systems: No.of Devices or Equivalent No.of Water I�� o.of No.of Dntn Wiring: • Heaters Signs Ballasts No.of Devices or E uivnlent { No.Hydromassage Bathtubs No.ofMotors Total HP Telecommunications Wiring: No.of Devices or E u€valent OTHER: Su .el►lath additlotw etail ifdeslred,or as required bat the Inspector of Brims. Estimated Value of Electrical Work. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. =�•-== ===INSURANCE=C0VERAGE:-Unless-waived-by=the.owner;nn=p miit:far I*''pe�faririarice ofeleatricnl vyorlri-rrie i=issue unless the licensee provides proof of llabfllty insurance including"completed operation"coverage or its substantial equivalent_ The undersigned certifies that such co a ge is in force,and has exhibited proof of s e o thg eririit i5 g o ice_ CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) �1// I certify,ander the pal►► tattles of p jt ry,it p f►IfOf?t2 tf0n on MIS appllcallon LF Irkza4alll plete. FIRM NAME: � U ti 1 LIC. Licensee: Signature LIC.NO.: (Ifapplicable, ' enrpt"' re lice niu tberfne.) /J ( Bus.Tel.No.' Address: �(� AIt.Tel.Na.: *Per M.G.L.c.147,s.57-61,security work reg es Department n0ublic Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the 1€ability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a enL Owner/Agent Signature Telephone No. FPER W T FE.E.-S � •" ClientM,3001 JUSAELECTRIC ACORD. CERTIFICATE OF LIABILITY INSURANCEI 11122110 PRODUM THIS CERTIFICATE IS ISSUED AS A(NATTER OF INFORMATION Doherty Insurance Agenc3N Inc. ONLY AND CONFERS NO MGM UPON THE CERTIFICATE P.O.Box loss HOLDER THUS CERTIFICATE DOES NOT AMEND.EXTEND OR 21 Elm Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Andover,MA 01810 INSURERS AFFORDING COVERAGE MAIC 8 NCO Juba Electric Co Inc ammRA; Admft Protection Ins Company S89 Chickering Road North Andover,MA 01845 aOURER Q aNSIRNER E COVERAGES THE POLICES OF WMIRANCE LISTED BELOW HAVE BEEN ISSUED TO THE M URED NAMED ABOVE FOR THE POLICY PERIOD RADICATM N071WffHSTANOING ANY REQUIREMENT.TERMOR CONDITION OF ANY CONTRACT OR OTHER DOC U ENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE WSUR/N10E AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDRIOrS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN RED ICED BY PAID CLAIMS. WSR TYPEOF WSURANIE POLICY NUMBER Pw ICY ERECiIYC uwS A GENENAL UARK Y 8500041056 09116110 09118111 EACHO IEMM $1000 000 X CCUMERCOL GENOM UABO" CAMIKS£To RENTED s100 � qWaAmmmmi 0 CU UM MAGE CJED OCCUR MEIS(A W um person) $S r PERSONAL s AoV aNJURY $1 000 GENERAL ACITE f2 000 000 GENLAGGREGATEUWTAPKJESPM PRODUCTS-COIPIOPAGG s2.000.000 �( POLICY IRO.JE LOG AUTOMOBILE UABRITY OOeD SSNGLE WR f ANY AUTO (Ea aoodwM ALL OWNED AUTOS BOOBY SNJi/RIf f SCHEDULED AUTOS (ftp—) HIRED AUTOS BOOBY BLRIRY S t NON-OWNED AUTOS (ft mmdoO DROPERTYOAMAGE a fwacumm) OARAOEuABRJTY AUTOONLY-EAACCMFAT S ANY AUTO OTHER THAN EA ACC f AUTO ONLY: AM $ ENC CJMIILMY EACH OSE $ OCCUR ❑CLAM MADE AGGREGATE 5 OEDUCTMUE $ RETENTRII! f S A Wo xwv% CDw8mTlo mw91087108Iq<` 09116/i0 0911ti/17 X IrCSTATU 0& EL EACH ACC CO#T ,1 008,000 OFFICERA/EMBERVWLUDEDTflymduaftumdw El-DISEASE.EAEMPLTWEE 111,000 000 SPECMPROVIMONSbMam ELDBEAW-POuCyuwT $1,000,000 OTTER { OMCNtlPTNWCFOPERAMMILOCATkONBrYE1 /EXCWMDIaADOEDWBMORSU*WIW MLpROy1StM14 Covering operations usual to Juba Electric Co.,Inc— CERTIFICATE HOLDER � CANCELLATION 1 ANY OF THE ABOVE OESCRO W POLICES BE CAMCEILEO BEFORE WE EXPIR MU jTown of Andover CATE TI F,THEM8uanstsumawBLEMOEAVORTONIPa In ISAYswRIrTEN Ebadcal Inspector TOTHECE MATE HOLDERNAIL10THELEFT,BUTFMMRET00080OVAL s PmWennedy WOSENOOBLkMIM OR LI UMM OF ANY KM UPON TIE MUML.WS#AWN OR 36 Bardet Street ROSESMAWN& Andover,MA 01810 NUInloll�o 7!A11YE ACORD 25 tIMM)1 of 2 #26673 DML 9 ACPW60RPORATION 1988 Date. . . . . . . . . . . . . ISO 4570 oq:,ho TOWN OF NORTH ANDOVER as 0 F " p PERMIT FOR PLUMBING 3 �Ss�cNUSE� _ r 1 This certifies that j'. . . . . . . . . . . . . has permission to perform �:_.J . . . . . . . . . . . plumbing in the-buildings of r . _. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... North Andover, Mass. Fee . . . . .Lic. Nor . . . \ -. . . . . .' '.. . . . . . . . . . . . . . PLUM8ING'INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ... Mass: .:,0at0-3 _ 1 Permit# �� Building Location y /G' ��•� �� Owner's Name Type of Occu cy 121,s--� New O Renovation Q,-- Replacemert O ns Submitted: "Yes O No el — FIXTURES _z ' X N V1 Z. Y < w 0 X } N W Y ).- U < ' W N43 Cc N X N < C _ .F X O _ _y d O U X ¢ 0 W FA be m y W } < p. N Z C 0. v < d < Q � C 4: < yr Q < N = 4: 4 CC 0 w 4: W y. W N fl N C 4: J O . Q . �r .rr O X S Y IL O i- < .k .0 W U. .0 W O X 4 , N f' Z O O N z z W O `U S i- m z N N < < O < J J < 2 It z •< O < F- at w o p ; s r. a ri v a a < 3 a m o SUB—BSMT. ,$ BASEMENT IST FLOOR 2ND'FLOOR r 9ROFLOOR 4TH FLOOR STH FLOOR eTH FLOOR, 7TH FLOOR .8TH FLOOR Installing Company Name A&A A AltAJ Check one: Certificate Address- <`1y'Lf - J� G�1A _� O Corporation �� L✓ � f� '0 Partnership Business Telephone' O Firm/Co. Name of licensed Plumber 1�VZ,4-1 INSURANCE COVERA : _ I have a curre t I y insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No If you have checked yM. please.Indicate the type coverage by checking the appropriate box. A liability Insurance policy O Other type of.Indemnity O Bond O OWNER'S INSURANCE WAIVER: .1 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 O Agent O Signature of Owner or Owner's Agent I hereby certify that all of the details and information 1 have submitted(or entered)h above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application Wit be In compliance with all Pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General taws. By &9n reoUUcensWWMW=bv TiUe Gty/Town Type or License:Master� Journeyman O fX I U ONL License Number a No 2349f Date...v..................��..� / NORTH °`<«`°:•'"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . .,: ....... ................................................. has permission to perform . .... wiring in the building of... ::�::�..:.? - .. ...................................... at..(,..(.......... ...... ....................... .North Andover,Mass. Fee&.................. Lic.No....'...... / ��J�...:...... Check # Oy/ ELECTRICAL INSPECTOR i QQ G WHITE: Applicant CANARY: Building Dept. PINK:Treasurer THECOMMONWEALMOFhUMMUSETIS Office Use only _ DEPARTAfiM0FPUBLIC&9FE7Y Permit No. 3 I BOARDOFFMPREVEMONREGM710NNS27CM IZ-0l � Occupancy&Fees Checked vAPPLICADONFORPERMIT TOPERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 i (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. AP PARCEL Location(Street&Number) 6Z Qi►- Z Owner or Tenant . r, n e Owner's Address Is this permit in conjunction with a building permit: Yes M No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead Underground No.of Meters New Service Amps / Volts Overhead Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below J7 Generators KVA and and No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch Outlets /J 4 No.of Gas Bumcrs No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons Nod of Disposals No.of Heat Total Total No.of Detection and _ Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained t Detection/Sounding Devices _ No.of Dryers Heating Devices KW Local Municipal Other Conncctions No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER Q. F It>SC P►asimrttotbetaq�manas e�atealLaws as<i YES ® NO Ihawaunalliabtlitykmmr PbhcywhrrgCaq Ca�aage MFvala1 Ih.sulxt Nddpmdcfsm=1otheOfce YES LrJ NO If}vtthace nrd tethetypeofoawagebyd tgthe ,,INS[JRANCE M BOND CIII IIETZ Fgaw Specify) - • % EslimatedVahreofE1ecbca1Wak$ WoktoStart hpecfimDr(eReqxsted Rough Fm SigoedtmderTrPtm�ofpajtuy FIRMNA1v1E Lioa>9eNa Sigtnhae LiaarseNo —F�29 .� BirsirmTelNo. (0 6 6 7 6 C, A1tTelNa OWNQZSINK ANCEWAIVER,IamawðattheLwarse&esnothamthe' cova aw crits stlsk iale4izalartasmgirodbyMassadw9&ci r IV1Laws andtha2rnysi uemthispa n_Vvaiwsti>isre anart (Please check one) Owner M Agent d Telephone No. PERMIT FEE$ �S ' Signature otuwner or Agent Location ram F(4`roti Z�c No. x-2-3 Date 1 5 "GRT" TOWN OF NORTH ANDOVER _ oL Certificate of Occupancy $ cHuBuilding/Frame/Frame Permit Fee $ Sa. s� so 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t Check # 3 I 13 4' 3 0 Building Inspector J TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMITa EI DATE ISSU �s SIGNATURE: Building Commissioner/Inspector of Buildings ate SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: fob Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(so FrmL e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R red Provided Required Provided 1.7 Water Sappty M.G.L.C.40. S4) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private 0 Zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 0 SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record amp( Address_ __ Address for Service 7., Signature_.. Telepho Q 2.2 Owner of Record: lJ Name Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: / Not Applicable ❑ Licensed Construction Supervisor: C 2 S O / License Number Add ss Expiration ate Sign lure Telephone �. 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address T r Expiration Date A Signature Telephone G) 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 buildin rmit. Signed affidavit Attached Yes....... No.......❑ SECTION 5 Descri tion of Proposed Work check all a Hcable New Construction ❑ Existing Building 11Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: r dC F—rt-t9 rJ c LT cZc 1 4� Ah� , �—C4 s' -c e4Q iB 0a" D 4 Co;S' st c b a4+ L �r i AL SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OT C AAL T E;Mty Completed by permit plicant . 1. Building (a) Building Permit Fee / _ Multiplier 4 •f 2 Electrical (b) Estimated Total Cost of c� Construction 3 Plumbing Building Permit fee(a)X(b) / a 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 p Fj p £Cry Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT `—"aas-Owner/Authorized Agent of subject property Hereby authorize to act on M-.behalf-in-alltters relative work thorized b_y this_buil ' g permit application. _ Si nature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION�y 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 me Signature of Owner/A 9 ent V Date v. J NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TB/MERS iST2ND 3 SPAN DHAENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CH VNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE I p ✓lae {>orr�nzouuea/�/ / acfzccae BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number CS 025991 I BiOhOW,02167/1941 Expires:02/07/2002 I _- Tr.no: 14925 Restricted T.o: 00 1 LOUIS GRANDE 11 DEBORAH DR READING, MA 01867 ! Administrator HONE INPROVEMEAT CONTRACTOR ' Registration: 109565 Expiration:. . 9121/00 E Type: Individual LOUIS GRANDE' IS GRANDE jj ADMINISTRATOR DEBORAH DR i READING MA 01867 . BUILDING DEPAR'TVl�ti T DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54,a condition of Building Permit Number 7-k 3 Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: - Location of Facility Signature of Permit Applicade Date i NOTE: Demolition t from the Town of North d perms Andover must be obtained for this project through the Office of the Building Inspector r � i ,1, r --3 The Commonwealth of Massachusetts Department of Industrial Accidents �� -= = � _—• Onlc_ eollayesllgatlons \ 1 600 Washington Street - s L,r Boston,Mass. 02111 Workers' Compensation Insurance Affidavit F-orma 11, /J M C: / v� ON t'c - 0v�� �c v Vjt=1704 /1,-��dv IU El irY phone# � g6 -- ] I am a homeowner performing all work myself. ] I am a sole proprietor and have no one working in any capacity ] I am an employer providing workers' compensation for my employees working on this job. KAn 3 oft I. LM 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: !)Mpnnv name: ddress: phone - ;. -1surance cs? omnia n y name: .. :�i............ ::,,;.,........ ...:...... .. ..... tv phone:#- Durance co.. :....:,. .::.. :,.;.... .,.:.,,.:;:• ,';:policy.#, ssE::;::... . ... . '`.ttH ad�lrttnnal:J21ttt71f�IIteeBJII al __ _ _ _Z ailuro to secure coverage as required under Section 25A of MGL 152 can lead to the impositioa of criminal penalties of a fine up to 51400.00 and/or ne ytars'imprisonment as well as civil penalties in the form ora STOP WORK ORDER and a Due ofS100.00 a day against me. I understand that a c)Py of this statement maybe forwarded to the Office of investigations of the DIA for coverage verification. ;lo hereby certify under a pains and penalties of perjury that the information provided above!s true and correct ,-/ ate gnaturc �C1 dr 'rine namc Phone# 44�- - X043 ofrcial use only do not write in this area to be completed by city or town official v city or town: permit/license JY rlBuilding Department C jUccasiag Board C3 check if immediate response is requiredOSelectmen's Office []Health Department contact person: phoned; nOther f )rcvuad 1/95 PJA) - . NORTIy ° `" Era.— <0�6 C. No. .3 � 177 Ao dover, Mass., COC HICHEWICK ADA`'ATED S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT............. .:2�,�V!?+ .. ..... ?.4-a. .f sad. s........................................... "' r "' Foundation has permission to mW.... .>.z.............. buildings on ............�.6..... / ..... ... !ls........................... Rough to be occupied as..AV PV. ...Fle.. ....,.-....c..5-..7kN....c..,v...4...�..... ..... ... ... `. .. .. r. . . .. : Chimney 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, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR_ Rough ....................... .. ............................ . .............................. ..................... Service BUILDING INSPECTOR Final Occupancy Permit Required t0 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. Location ?6L) LAIJ— No. / Date �ORT� TOWN OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ f7l Foundation Permit Fee $ sacHUSE Other Permit Fee $ Sewer Connection Fee $ ` _ J Water Connection Fee $ TOTAL $ Building Inspector 1 u 0 45/17/99 14:04 71.00 RAID Div. Public Works � s � � J � = �Y 9c plc ak ak plc 9c* l t F:RM1T NO. �(O/ AI 1 I (CATION F'OR PERMIT TO BUILD RTI( ANDOVER, MA NI NI'NO. 0(o1OI.Nu. /� Li 2. RECORD AF nwNERs1III' DATE BOOK PAGE n)NE l/ SUB nIV. IOTNO. (!/ I.O('A I I()N L D .l �L ' PURPOSE OF 13011 DING cE X S s /Q►'l, 11 I h J ()WNER'S NAME 1lzf- J l� 4 �I() IIFc 2 - �iV!12 1 ()WNER'S ADDRESS A / BASEMENT OR STAB ARC(lil'E(-1'S NAME L• .SIZE OF FLOOR TIMBERS 2 ND 3 RD lit ll DER'S NAME E r s74n. C" o r SPAN DIS 1 ANCF TO NEAREST BUILDING DIMENSIONS OF SILLS DIS I'ANCE I ROM STREET DIMENSICNNS OF P(JS-I S DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE IIEIGIIT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUIl1)ING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WI L.1.BUILDING CONFORM TO REQ111 REMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSI'IIC'TIONS 3. PROPERTY INFORMATION LAND COST Ak R EST.et-['X;.COST O PAGE- 1 FI I I.OI TT SECTIONS 1-3 EST. BLDG.COST PER SQ. FT. f EST. Bl.lx;.COSTPER K NOnNl EI ECTRIC METERS MUST BE ON OI JTSIDE OF BUILDING SEPTIC PERMIT NO. A'1-1 ACHED GARAGES MUST C(NJFORM TO STATE FIRE RE(i(ifATiON5 4. APPROVED BY: C PLANS MUST BE FILED AND APPROVE=D BY BUILDING INSPECTOR BUILDING INSPECTOR DA If:1 11 E-1) OWNERS TELA MAY 7 l^ f f � I• �( ; 9 I J } CONTR.LI('JI o�� ZT� — \IIiN,\1 i(N OWNIiR(N(Al lk)RIZLI)A(iliN'1' 111 1 !I t ��FT j' C�L.,tib(\'..' ��.�."s�... ?e'NEt;\i ti I'1101111GRAN IED 6-111 '9301 OR Thy own of And 0 m -jK Z '9s ` dover, Mass., 19 A.0 y 9 OWE - S E BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System T �/ .. ........................................................ BUILDING INSPECTOR THIS CERTIFIES THAT.. S�.! ..(�.�0 .�..l�.a........... 'e N Y y Foundation has permission to erect..2 .. .......... buildings on ...... .. ........plQ. O.U . Rough I � 0 Chimney eyto be occupied as.. . ....... ...............5.� . G . . o 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, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough V.IrG f* Final O PEB.MIT EXPIRES IN 6 MONTHS 1 :3 3 UNLESS CONSTRU NST S ELECTRICAL INSPECTOR Rough 000 #0001 00qk +41 A00 4 4000 # ......... ./Y(....&%....... ............................. Service BUILDING INSPECTOR Final 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 No. Smoke Det. The Commonwealth of Massachusetts Department of Industrial Accidents ff Off/ceORMOS9981/ens - � 600 Washington Street i Boston,Mass. 02111 Workers' Compensation Insurance Affidavit a ,LJ /10 NS � G 6'.J location: 77—/ ./7`CGU i /� city NA uin 719 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 77 . � I am an employer providing workers' compensation for my employees working on this job. ti �.,�. company.-name address: city• phone A. insurance co. _ otic # 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: eomoanv,name address. city: phone#` insurance co. MUM company name: dre s ci h p •ne#: Insurance co policy# t1` tc "ddltlgrcaheaecessar � ��£rw . � �a Failure to secure coverage as rc wrcd and er Section 2 A � g q G 152 can le ad to the Im osition of crI mm I a penalties P p s of a fine up to$1,500.00 and/or one years'imprisonment as well:Is civil penalties in the form of a STOP WORK ORDER and a fine of 1 5 00.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA IA for coverage verification. I , do hereby certify under fire in and penalties of perjury that the information provided above is true and correct. Signature Date — S - 7-9 Print name ENN E . `C C—mac-_.�,. -. :_.._ . �r p __ ._. _._. Phone# 7"g'I9�/'s7.0 official use only do not write in this area to be completed by city or town official city or town: permit/license# -Building Department �LicensingBoard' '—"' []check if immediate response is required []Selectmen's Office []Health Department contact person: phone#; -Other 4 r" (revised 3/95 P1A) •':,iau..:r•a:,„ ,-:pE'"' 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, 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,to er, 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 compiiance 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. ,x z %1"ri /Szss J:, NE4111 // 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 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. U-157,11 fi/ 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 permii/iicense 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. k �' d f - ti K z✓tG f✓y u 6 i ' is'°r'si f/9% ,/ gTpym s The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 i I 2428 KEEN CONSTRUCTION CO. e 21 HEWITT AVENUE PROPOSAL NORTH ANDOVER. MA 01845 - All home improvement contractors and subcontractors j Tel: (978)691-5201 engaged in home improvement contracting, unless r Fax: (978)682-3231 specifically exempt from registration by Provisions of Chapter 142A of the general laws,must be registered with Submitted -r - _ _/ the Commonwealth of Massachusetts. Inquiries about To. registration and status should be made to the Director, Home Improvement Contract Registration,One Ashburton . .._ ___ Place, Room 1301, Boston, MA 02108 (617) 727-8598. Z N... Owners who secure their own construction related /F7 permits or deal with unregistered contractors will I be excluded from the Guaranty Fund Provision of MGL c. 142A. PHONE DATE REGISTRATION NO. F.I.D.N0. MA. H.I.C. 108383 04-325-8052 i > C/S = Customer Supplied S + I = Supply + Install We hereby submit specifications and estimates for work to be performed and materials to be used: I '� J<<�. L J.0 li�'... ._'../G,-/ .. �l-i�a 1.�t � ��C x......./4.._ /_...__�...f..s._�</,�j ._�.-'` %��..� l i...�.r•ri_�`c�, jrJ /�'.[.1✓/, .,f..... �!'�� ._. .� ..- �i//......`lL �L...J /(.^/ .S._/_. �.! 1_!. ./6.1 �._._L.C. L.!L�✓.J L..[..! l i?( cC1..... /..%Ja' ,2.C^..x:.._ �� .L„...C_=.y.._I .�r..`Irlc rJ...........� j __. ..__.. ..... i —--- ---_” _ ...... Construction related permits: ............................................................................................................J,..................................,............................................................................., .,.,.,..............,..,..........,,,,........,...................................,....................,........,...................................,.........,......... i I �c.............-................,.,...,.............,.....,....,,.....,...........,.,..,........................................................................................ WORK SCHEDULE Contractor will not begin the work or order the materials before the third day following the signing of this Agreement,unless specified here in writing. Contractor will begin the work on or about - �,L%'/ (date). Barring delay caused by circumstances beyond Contractor's control,the work will be completed by ( <�``2 (date). The Owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor shall not be considered as violations of this Agreement. WARRANTY The Contractor warrants that the work furnished hereunder shall be free from defects in materials and workmanship for a period of IV/-L following completion and shall comply with the requirements of this Agreement. In the event any defect in workmanship or materials,or damage caused by the Contractor,his subcontractors,employees or agents,is discovered within one year after completion of any job,including cleanup,the Contractor shall,at his own expense,forthwith remedy,repair,correct,replace,or cause to be remedied, repaired,or replaced,such damage or such defect in materials or workmanship.The foregoing warranties shall survive any inspection performed in connection with the agreed-upon work. We Propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of dollars($ Payment to be made as follows: / % ($`�%�'`' ) upon signing Contract; KENNETH B. KEEN C' (� r '�l Name of Contractor/Designated Registrant s r, 21 HEWITT AVE. /° ($ _) upon completion of Street Address % ($ ) upon completion of N. ANDOVER, MA 01845 City/State ! shall be made forthwith upon (978) 691-5201 (978) 682-3231 I , ($ ) completion of work under this contract. Phone Fax ' Notice: No agreement for home improvement contracting work shall require a _ >down payment(advance deposit)of more than one-third of the total contract price Name 0 Salesman oc the total amount of all deposits or payments which the contractor must make, ih ' ? 77" ` advance, to order and/or otherwise obtain delivery of special order materials and Amari ed signature equipment,whichever amount IS greater. Note: This proposal may be withdrawn by us if not accepted within days. Acceptance of Proposal -I have read both sides of this document and all attached documents and accept the prices,specifications and conditions stated. j I understand that upon signing,this proposal becomes a binding contract. You are authorized to do the work as specified. Payment will be made as outlined above. You, the Buyer, may cancel this transaction at any time prior to midnight of the third business day after the date of this transaction. Cancellation must be done in writing. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Signature Date Signature Dale IMPORTANT INFORMATION ON BACK 0- -- ------------ - -------- ------- - - -- ------ - i North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: 5 i1 im P - H r L g r: I I (Location of Facility) 4Z A Sfidnature of Permit A plicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Location (00 A—t s ��'1I`•QtZ. No. Date S:' N°"'" TOWN OF NORTH ANDOVEN pr ,�ao p Certificate of Occupancy $ _ Building/Frame Permit Fee $ +tie �ss„C,,,jSEt Foundation Permit Fee $ __ Sq_ Other Permit Fee $ $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Z 5'n3 Building Inspector "'ro p h 7$ Div. Public Works PER111T NO. �� PAGE 1 APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. MAP+40. LOT NO. 2 RECORD OF OWNERSHIP iDATE BOOK 'PAGE ' ZONE SUB DIV. LOT NO. I LOCATION JP0 A-rTa1%k t-�M rp. PURPOSE OF BUILDING rDA11t * OWNER'S NAME J"05,elW IV/V`G�� NO. OF STORIES 61ZE OWNER'S ADDRESS && jPA73pzv BASEMENT OR SLAB ARCHITECT'S NAME /L//cl.4 6 L ,• 4 wiowv SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME / ,IT .ON / / SPAN DIdTANCE TO NEAREST BUILDING /oU. ¢. DIMENSIONS OF SILLS DISTANCE FROM STREET /© POSTS DISTANCE FROM LOT LINES-SIDES !e REAR " " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST •SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. 'PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING INSPECTOR SIGNATURE OF OWNE AUTHORItelD AGENT FEE -J-) e.—. OWNER TEL.# 6g s ! PERMIT GRANTED 4 `yo CONTR.TEL.# r r 19 CONTR.LIC.# 62, 46 "1 L (9 95 c4t� a S Ly� BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY S� iFJ RIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY ICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- F APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION —I S INTERIOR FINISH CONCRETE 3 1 2 13 CONCRETE BL'K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 1/1 1/1 '/, FIN. ATTIC AREA _ NO B M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARMU D ASBESTOS SIDING _ COMMCN _ VERT. SIDING ASPH.TILE STUCCO ON MASONRY �— STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR _ 1 ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) _ GAMBRELMANSARD TOILET RM. (2 FIX.) FLAT A SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. w TIMBER BMS. &COLS. STEAM STEEL BMS. 8 COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING NORTH Town of �r 4Andover -A . 7. �J in y over, Mass., 6���� 19 S T' S COCMIC MEWICK ^• I� V 7�ADRATED H BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System .^ BUILDING INSPECTOR THIS CERTIFIES THAT.... OSS.t'1-4......" Tl1E.J !............................................................................................... Foundation has permission to erect... -.tbQt-K.o1y:.-l-Obuildin s on ..�Q..7?A7T..AtA.....I-AN- S................................. g Rough to be occupied as bA.t�(11. .R-0.0M. .....(NY.F-Z...FC.IJT••.•.QPA�• �Y���• �� Chimney .provided that the person acce ting this permit shall in every respect conform to the terms of the application on file Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings In the Town of North Andover. u0 CkAy� �` „ PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final �ktG* l vZ(c58 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONUC T Rough .................. Service BUILDIINSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or . landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: 1, ,VAI CD y Phone LOCATION: Assessor's Map Number Parcel Subdivision. // //�� Lots) Street (e /14�r?Z5 Al St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Department < Received by Building Inspector Date COLLOPY ENGINEERING CONSULTANT 65 AYER STREET ME WEN, MA 01844 FRANCIS H.COLLOPY REO.PROPENIONAL ENGINEER " Raid ON)985.7989 R c Offt(hos)504469 �T D�NAVMIA Fax: s .� �TM OiAr�� May 15, 1995 FRANCIS H. 3 COLLOPV 172 Building Inspector Town of North Andover CNA1»�M� No. Andover, MA 01845 Dear Building Inspector: I am writing in regards to the renovation being proposed at the Kennedy Residence at 60 Patton Street, in North Andover, MA. This is to inform you that I have reviewed the proposed changes and have assisted Mike Antoon of Antoon Construction with the framing member sizes which consist of a LVL ridge beam in the garage roof and a steel beam as a main beam for the floor over the garage. Also, Z have sized a steel beam(or alternate LVL) for support to replace an existing support wall in the breezeway area. For this beam, I considered the appropriate snow load build-up due to the adjacent wall. and high roof. I have reviewed and stamped the final drawings of Mr. Antoon and found them to meet the framing requirements of the Massachusetts State Building Code. If you have any questions concerning these matters, Please do not hesitate to call this office. Sincerely, COLLOPY ENGINEERING CONSULTANTS Francis H. Collopy, P. E. Structural Engineer cc : M. Antoon LN( MLLKINIii UUN,ULIAN1, er 65 Ayer Street CALCULATED BY DATE METHUEN, MASSACHUSETTS 01844 ' ...' - (508) 685.8069 CHECKED BY GATE ., SCALE lie 2 3/�• 9 V P ... NarR�•.�►� �JlOxzb S��yp Md01Ct2*1{SOO&WOa&i mw0&ft.,cr nMKMi.Tool*P"fuipE414mma m l:Obi oudbbobuoly WLLurr GIVulIVGGfElIVl7 , r,,.a- Vr/ ros Kr—NNL.,v 4 S°I DA A"s;-c, . • COLLOPY - -- Y ENGINEERING CONSULTANTS- SHEET NO, •OF //. 65 Ayer Street CALCULATED sv Fy C DATE METHUEN, MASSACHUSETTS 01844 (508) 685.8069 CHECKED BY DATE SCALE L elms 3 '4): 1)F/S /eilair + r r,00uc1104, „sAM�10a��►MaatQ.k'olookoft owl,noMPllflmuFREE 14*20M o OFFICES OF: 4? Town of 120,Main Street APPEALS : NORTH ANDOVER North Andover. BUILDING •t'`�:::�.• Massachusetts O 1845 CONSERVATION a•` DIVISION OF HEALTH PI--\NNING PLANNING & C01iMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR In accordancewit� the rovisior5 of NIGL. c 40. S 54, a condition of Building Permit Number oL, I is that the debris resulting from this work shall be disposed of in a properly licc::tscd solid waste disposal facility as defined by MGL c III, S 150A. The debris will be disposed of in: (Location of Facility) Siena A oY Permit Applicant Date :TOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number CIE;" 20-7 Date is I tc • THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS Tl--AM t 0 XXq M ft(M GAP— IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. to CERTIFICATE ISSUED TO Ca�!-1 iCmNKEOY ADDRES 40 R,418H 11A 'i ,JJACMUS� n Inn or f f{{[[ jq { r s r i NORTF�I Town of ic .over 0 C)No 20-04 r ort dower, Mass., 4 19 , 4. fr L ID ty BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THISCERTIFIES THAT.......... ...... .-S.*..(. t:-:..,.:;`................................................................................................ Foundation �' r has permission to erect...d;.t:. ..��: ..l..�,r..9...:..; buildings on .........1 ..................................... Rough'. to be occupied as . .=.�.i;:,t.�t:� ' ':.::,��..,.....::a.�.:!.......0 :{.. .:..:,............a:,::: :...:. :i..a::+..?::. �r .ti.tw...:r:: ::,:.i:...t.'{. .�.1!4.� r�� -d' v provided that the person accepting this permit shall in every respect conform to the terms of the application on file InFinal 'k. this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of ". Buildings In the Town of North Andover. !4`q : r { , ,1.f. q ly PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough S . cI� Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR ' UNLESS CONSTRUCTION STARTS41„Rough?' 41:�il '�yG � i ` Service ..............................................................BUILDING INSPECTOR Fin 714 � C, . Occupancy Permit Required to Occupy Building GAS INSPECTOR Rouh Display in a Conspicuous Place on the Premises — Do Not Remove 61 -1,4 ,No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. ✓ �� PLANNING FINAL CONSERVATION FINAL Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTiNG (Print or Ty e) Mass. Date -71 �6 19 Permit # c Building Location PCAMLA) Owner's Name Type of Occupancy /'e.-S New ❑ Renovation ❑ Replacement 8 Plans Submitted: Yes❑ No.N N W W x Z ¢ N N ¢ O _ W J N W O U C7 F = W O W ~ a ¢ _ N sQ 0of F- Q WQ m ZO O puf-y 7- LU w O aUS N O W < Z > W W J rwW 7 LL 0 1,- Z W O > W 4=wJ H W OW O W S Q w > W Z Z Q Q Q0 0 W G_ C S O C7 Z u. D Cti J U C > p 6 C"' O SUB—BSMT. BASEMENT J 1ST FLOOR 2ND FLOOR I 3RD FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR InstallingCompany Name METROPOLITAN PLUMBING P Y Check one: Certificate AddressNorwood Commerce 5r., BldRIP g.21 ® Corporation reet NORWOOD MA 02062 ❑ Partnership Business Telephone �bll 1) ItQ-11 779 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter L1-1117// INSURANCE COVERAGE: I have a current liability insurance policy or.its substantial equivalent which meets the requirements of MGL Ch. 142. Yes S No ❑ If you have checked res, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent [I 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 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 TVoe of License: Plumber Signature of Licensed Plumber or Gas Fitter Title ry Gasfeter � Master License Number City/Town _.�.___ T_I 4Journeyman APPROVED(OFFICE US ;-ONLY-T-- ` e�E�lEtis�.� , BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME d -('(PE OF BUILDING LOCATION OF BUILDING PLUFABEII OR GASFITTER LIC_ NO. PERMIT GRANTED .' DATE Io - C=> GAS INSPECTOR r� b.' Date... .:'AA :.... ?4 cf,ND oT e TOWN OF NORTH ANDOVER g PERMIT FOR GAS INSTALLATION SSACHUSe This certifies that'!.Q 11'.A44x '�a-'k .i. • r' J has permission for gas installation . 8' .�6f: . .f.'�? .?, ... . . . in thebuildingsoff . . . . . . . . . . . . . . . . . . . . . . . . . at f..- ;'. . . . . . . . , North Andover. ass. FLic. � V� 7G ;:INSP*ECTOR* WHITE:Applticant 0C RY: ✓ �.� . . . Building Dept. PINK:Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITiING � (Print or Type) NORTH ANDOVER Mass. Date (,--�,f Building Location D Permit # 7 Owners Name Ke,✓)V,jx ` New 7L Renovation II Replacement Plans Submitted D &U v� U3 s p m to us mt- c. O < w G1 Z M W 6 W � 0 �� „ 4 "l N � W d Q W J t� }t/ � 0 Lu O ? U. h` W •t F- US 0 0U. fes. C @ 6 SASEMF-MT zsT FLOOR 2ND FLOOR I I I I I I I I I I I I I I I I ! I I t 3RQ FLOOR ( I I ( I I I I I I I I I I I ( I I 4TH FLOOR I ( ( I I I I I I I I ( I I 5TH FLOOR ( I I I I I I I M I I I I GTHFLOOR 7TH FLOOR I I I I I ( ! STH FLOOR ( I I I (Print or Type) Check one: Certificate Installing Company Name ,�vr r - Q Corp. Address Partner. rm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverace. Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �Lher type of indemnity Q Bond El Insurance Waiver: I , the undersiened, have been made aware that the licensee of this application does not have anv one of the above three insurance coverages. Signature of owner/agent of property Owner = Agent I hereby certify that aU of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of my knowledge and Mat ad plumbi" work and tnsadations ptsfarmed under-Permit issued ror this application w' in compliants with all pcttneat Provisions of the btassachusetrs State Cas Cade and Chapter 14Z of LU Genera!LAWL By T1PE LICENSE: ^ Plumber Title I Iumber igna a of Licensed City/Town- 1 �,,�aster lumber or Gasfitter Journeyman X99 APPROVED (OFFICE USF- ONLY) License Number s" v— palegiv Date 1847 ,AORTN TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION-1. • i i . 9SSACNUSEt This certifies that has permission for gas installation . . . . . . . . . . . w in the buildings of . .� . .: .! . . . . . . . . . . . . . . . . '' at ?�. '.f`L . . . . . . . . . . . . . . . North Andover, Mass. Fee.A � Lic. No..`� � r � 1 fi 14:57 15.00 RAID GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File:., „-,a.+:,,.g:=uri#+,:4 ,],i.rslM,i.et'.w.e._ n'��✓ >ix,1,.+s+:,#', ;.c xu.,ie., Office Use Only II��°tt ulll: Liam unwralt1 If faggar4imtts Permit No. d� i9quiTtmerit Df 11ubllt �S"iifPtq Occupancy&Fee Checked—XII I r BOARD OF FIRE PREVENTION REGULATIONS 521 CMR 12:00 1 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ( - 9^—"— (X* or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform e eeltrical k described below. Location (Street & Number) Owner or Tenant e Owner's Address Is this permit in conjunction with a building permit: Y S No El (Check Appropriate Box) Purpose of Building C-,?5 Le �' "'r' Utility Authorization�--� No. Existing Service �w Amos/ d ��Volts Overhead !_� Undgrnd — No. of Meters New Service Amps —J Volts Overhead ❑ Undgrnd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electric I Work �✓ ��" ©✓ems eXJ H� g 5'P No. of Transformers Total Hot No. of Lighting Outlets ( No. of .,ot Tubs � KVA No. of Lighting Fixtures Swimming ?pAAbove— in- oi grnd. '_ grnd. ' Generators KVA ✓ No. of Emergency Lighting No. of Receptacle Outlets 1 No. of Cil Burners I Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Totai No. of Detection and No. of Air Cond. No. of Ranges I tons Initiating Devices No. of Disposals I No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers I SpaceiArea Heating KW Detec;ionlSounding Devices — Municipal No. of Drvers Heating Devices KW Local _ Connection r Other No. of No. of Low Voitage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs I No. of Motcrs Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of ` assac. acts general Laws I have a current Liability Insurance Policy including Comoiet peranons Coverage or its substantial equivalent. YES yN0 have suomitted valid p of same to the Office. YES - NO = If you have checked YES. please indicate the type of coverage by checking the aper late box_ / l� r /�- INSURANCE _ BOND -OTHER - (Please Specify) (Expiration Datel Estimated Value of E!ectrical Work S Work to Start I9-/9 -2-5- Inspecuon Date Recuested: Rough �_ S Final Signed under the Penalties of perju : FIRM NAME v � LIC. NO. LGL= Licensee 1 Signature t LIC. NO. c Bus. Tei. No. $ 3 0 Address `'�� Alt. Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insprance coverage or its substantial equivalent as re- ouwred by Massachusetts General Laws, and that my signature on tnts permit application waives this requirement. Owner Agent (Please check one) Teleonone No. PERMIT FEE S (Signature of Owner or Agent) x-6565