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Miscellaneous - 66 COLONIAL AVENUE 4/30/2018 (12)
66 COLONIAL AVENUE 21011070000.0 D a t e TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ss+cHU This certifies that.... .................................................. has permission to perform....PISMPO'k............................................................ plumbingAnthe buildings of............................................................................................. at.6 ........................... ............. N Andover, Mass. Fee..} . ..Lic. No.lSd,:K3.... ......... ......... ................................ PLU ING INS ECTOR Check ?a r tl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4� CITY cr _�&44cr MA DATE f I PERMIT# JOBSITE ADDRESS vg OWNER'SNAMEEa b �lk^• POWNER ADDRESS _ TEL =FAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL © RESIDENTIAL PRINT (( CLEARLY NEW: 4 RENOVATION: REPLACEMEfd-T-fiK PLANS SUBMITTED: YES NOD FIXTURES'l FLOOR-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB -..._....-! __--_. m! !== --- __i CROSS CONNECTION DEVICE _a_! - ! --JL— .____ a DEDICATED SPECIAL WASTE SYSTEM _ ! .__..__1 ( .___.. ! .._._1 ._-_.J � ! -_-- ( -. - --J -- t ! I DEDICATED GASIOIUSAND SYSTEM ! DEDICATED GREASE SYSTEM ---.�j L-,-.J ------i - ----! �! ! DEDICATED GRAY WATER SYSTEM ! .... ! —_! __._..1 _ ( __.-.-- __--- - -- - ( _J ! - - 1 ! DEDICATED WATER RECYCLE SYSTEM I 71._._.._._! __1 --.j _.___..__ ___J r_.! __-._._l ._.-.___f DISHWASHER ._! ----( __j DRINKING FOUNTAIN FOOD DISPOSER i ..._ _! ___._-J __. FLOOR/AREA DRAIN ! _ __1 -..__.._► .__� _._ _...__� ______1 .__.-__! _.__._ ..___..._ _...._.__! .-_.�l i ._..____f INTERCEPTOR KITCHEN SINK ! LAVATORY ROOF DRAIN __ _! ._-_��! ___^! ___ E ___.J _ I ._.._J ._.. ! .___-_! _..._J ._......_6 ____._J I -___1 SHOWER STALL __1 ._._.A_ __1 ____ ____J ___._ _.__1 __1[:—I F— __--.1 _.-__J —._-. SERVICE/MOP SINK __ I ___._I __ _,! -___J 73-_..__l ._.___J __--. - ! _-._ 17 J _._____! OILETi _-- --_-- I E ___- ! __ _-__J ___.? .�_ _ _... ( -__ j .------ ------! `;JRINAL 1WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I [ _ P I i ! __. I ._.____I ____..1 _! _. l ! I WATER PIPING I ! _. ...__ ! -_.---_I ! ..._ J _-- I _( I OTHER _ _ I t. _ ( _._._._--.� . _.._! _ ! _ INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESA NO 01 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POL OTHER TYPE OF INDEMNITY Q BOND 0 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 Q AGENT ��]! SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' ce wit all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE# [) 4%3 C SIGNATURE M _ Jp n] CORPORATION F11#_=_ ._I,_IPARTNERSHIPP# I LLC E=_ ,,,_.I COMPANY NAME ADDRESS CITY ,rRd��. _ __....__.. _._..__�STATE ®ZIP 011L TEL mil -fit --� � kit FAX I CELL EMAIL ��;� -- "`-- 1`�-- S rhe! -- ROUGH PLUMBING INSPECTION N&FA BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts z F Department of lndustrialAccidents I Congress Street, Suite 100 Boston,MA 02114-2017 yV:V www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY-Applicant Information Please Print Legibly Name(Business/Organization/Individual): o.°�. Address: 35- C.loA,-4 01- City/State/Zip: ' d Phone#: -7J( k P61 Are you an employer?Check the appiopriate box: Type of project(required): 14-11 am a employer with employees(full and/or part-time).* 7. ❑New construction a sole proprietor or partnership and have no employees working for me in 8. (]Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Electrical repairs airs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12.Q Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.# 14.El Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box mustattached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workeis'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cer 'ay nder the pains andpenalties ofperjury that the information provided above Si nature, is true and correct. rG � Date: . Phone#: �� 4�4 & Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): LLthe ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector on: Phone#: 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date....� ....�. ...��. .......... pF NOwrM, TOWN OF NORTH ANDOVER n PERMIT FOR WIRING * w, ss�caysE -�- Thiscertifies that ....................................... ............. ................................................................ has permission to perform ... !G. ?. ..� ..^ ...... ............................ wiring in the building of........... .;^z......... ...................................................................... at .. .... ......................................North Andover,Mass. Fee..... j..�......Lic. No2.�l"l . .................................................................................... I C� ELECTRICAL INSPECTOR Check# r - � a -� Commonwealth of Massachusetts Official r}Use 0 ly g,� r Department of Fire Services Permit No. Jy"tlQ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: 1 y !r[t City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention�to perform the electrical work described below. f Location(Street&Number) 4 C6 16h iA�V UY Owner or Tenant (3600 J Telephone No. (� Owner's Address 0� Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service M Amps 120 / Zq0 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: 62t;.I4 �hp F � Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total f Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets 2 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches 'L No.of Gas Burners No.of Detection and Tot"� Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained . ............................................................ Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* � No.of Devices or 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: F-s", ' Attach additional detail if desired,or as required by the Inspector of Wires. 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 COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. y CHECK ONE: INSURAIQCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: . (si f�S�= ( nrtlq 11 LIC.NO.: A `Zig — Licensee: Sj*ck &01keT Signature LIC.NO.: C-S-65-2k (If applicable,enter "exemp "in the license number e) Bus.Tel.No. 39'V'i21 Address: S'3�-( A At Otc.Et°3 Alt.TeI.No.: *Per M.G.L c. 147,s.57-61,security work requir69 Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ 5J�-- Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS ECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: / L -/h. d FINAL INSPE ION: Pass M V Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com , r The Commonwealth of Massachusetts { Department of Industrial Accidents M X Congress Sheet,S�ite 100 Boston,MA.02114-2017 �d-t,y SVS www mass.gov/dia Workers'Compensationlnsurancd A.fiidavit:Builder;/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING,A•UTHOMY. ' „Please Print Le 'bl '� A licant Information � ganization/Individual): Name(Business/Ox Address: P6 5- 31 City/State/Zip: k"V-(63 Phone#: Are you an employer?Chec.'the appropriate box: 'Type of project(required); l.pg I am a employer with�_employees(full and/or part-time).* 7. []New d6nstruction 2.Q I am a sole proprietor or partnership and have no employees working for me in 8. []Remodeliing any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.I]I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10[]Building addition 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.�Electrical repairs or additions proprietors with no employees. 12TQ.Plumbing repairs or additions 5.❑I am a general contractor and T have hired the sub-contractors listed on the attached sheet. 13.• Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14. Other 6.Q We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and vwe have rio employees.[No workers'comp.insurance required.] *Any applicant that chdcks bbk 41 dust also fill out the section below showing their workers'compensation policy information. t Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such $Contractors that check this box must attache additional sheet showing the name of the sub-contractors and state whether or not those entities,have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer tliat is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: T V s'$—8Z Expiration D ate:. fob Site Address: �° d(Nrd Aa—city/state/zip— ____1----Attach a copy of the workers' compepsation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required underMGL e. 152,§25A is a criminal violation punishable by a foie up to$1,500.00 enalties in the form of a STOP WORK ORDER.and a fine of up to$250.00 a and/or one-year imprisonment,as well as civil p be forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement may coverage verification. I do hereby certify under the pains a d penalties of perjury that the information provided above is true and.correct. Si ature: Phone#: official use only. Do not write in this area,to be completed by city or town official. City or Town- Permit/License# Issuing Authority(circle one): i 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 4: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract 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 xequired." 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 Pleasb fill,out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if rice§sary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill.out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 wwwmass.gov/dia Corttmonvvear'h of l+•.as,- husetts Divisron of Registratiofr, board of Elects STEVEN?�i �y GI !'? 21-15 TUCk PO BOX 4'. PEPPERS \- Master Eleci�21845-A }-- 21845-A 07/31/2016 �� J2 — 009386 License N,,, Expiration Date Senai Nc 0 i - \a ao � o o � o � o � a � D oac� o 33 WALKER ROAD NORTH ANDOVER , MA 01845 ( 508 ) �-�;� r� 6s5- � 35n �Q a� Op EM lujil 0 1 o0 Im 00 00 I 28 X 40 COLONIAL - 4 BEDROOM — 21/2 BATHS — 16 X 24 FAMILY ROOM — 2 CAR GARAGE UNDER . 1046-10414 -_ ■■■ _ -__ -_ ■■■ -__ �_ ■■ ■■■ ■■ __ _ _ ■■■ __ __ _ ■■■ -_ -_ . u ■■■ _ _ _ ■■■ __ _ _ _ ■■■ _ _ _ ■■■ = _ - -_ ■■■ - _ _ ■■■ - _ -_ ■■■ __ _ __ ■■■ = _ _ __ ■■■ - _ __ ■■■ -_ _ �_ =_ _ __ ■■■ ONE ■■■ = = ■■■ 11M= = = ■■■ - = ■■■ =__ C �� - - ■■■ = = ■■■ - S i 1 . � a► ■_■■ �t- -� ■■■ =. ■■■ ONE ■■■ _ ■■■ - ■.■ ■■■ ■■ ■■ ■■■ �� ■■■I ■■■ ■� ■■■ IMEN ■■■ no ■■■ MEN -= = ■■■! ■■■ USE-mm, _-= ■■■ ■!/ -73,50,11, - ■■■ ■■■ it 11 -- ■■■ ■■■ ��■■■ ■■■ — ■■n ■■ —son son ■■■ ■■! _==__= ■■■ ..�_men III -=_ - son I logo ■/Boom -_- ilii!! � .�.� • • • • • • • • I11 !B!! 11, ■/Bill --f= • • 1 1 1 ME -- �� -- ? •• . • .I• •• • 1 16'134 20'2 '2" 5'6" 14'13/4" 3'0" 2'6" 5'0" 2'6" 3'13/4" 3'10/4 118 4'8/4" 2'9" 2'9" a 7'0" 7.13,4" 6'0" SLUING �y CD --FAMILY ROOM BREAKFAST KITCHENNo oa STUDY CDP CD (Vaulted) O N - - - - - - - - - - - - - - - - 2'4p O OLo v o N --------- " J- N or sO 26 2'8" 0 0 O to — — — — — — — — — — — — — — — — N o' " 00 c CD UP 17 DINING ROOM FOYER LIVING ROOM o Lo 0 0 0 CD 2,0• 310" 10' a CL CL IL 4'0" -616"- 316" 310" 3'0" 310" 310" 316" 6'6" 1. 4'0" 4'6" 7'0" 4'6" 14'0 12 0" 14'0" 16'0" 40'0" di FIRST FLOOR PLAN v 3/16 = 110" 10414 3-9 14'13/4 10'4n/4" 8'4" 712" 7'0" 7'13/4 n 5'4�/4 n 5'0" 314n 5'O" FLOOR PLAN GENERAL NOTES: 1. Smoke detector systems shall be Type I I I in conformance with �� E0 [ 3401 . 14 .1 .1 ] . Detectors shall be located as follows: BEDROOM #4 _ A mininurn of one per floor and basement, one per each 1200 sq. ft = or part thereof. One shall be located outside of each separate 0. CL WALK-IN sleeping area and/or near the base of, but not within, each stairway. ° m o 2,On N CLOSET o [ 3401 . 14 . 2 ] i 2. Ventdition:Kitchens and bathrooms shall have mechanical venting "' 3 0 systems that provide 20 cfm/occupant.Bathrooms with a window which Igo opens directly to outside air, no mechanical ventilation shall 24 2'4" be necessary [ Table 3401-2 ,3401 . 5 . 2 . 1 ) . 2 — 3'0" /�l co 3. Light and ventilation:All habitable rooms shall be provided with co CLOSET aggregate glazing area of not less than eight (8) per cent of the 00 floor area of such rooms.One—half (1/2) of the required area of CLOSET = N glazing shall be openable. N , " 4. Hall and stairway widths shall be a minimum of 3 feet clear. 2 — 3 0 M.21 216" Handrails may project no more than 3 1/2" into the required width. 3401 .10 .4 .2 , 3401 .10 .8 8'0" 6'13/4" io _ CL.411 co BEDROOM #3 . BEDROOM 12 -o M BEDROOM #1 Floor of closet h has a sloped floor J Pi to maintain headroom clearance for the o stairs below 4'0" 6'6" 306" 6'0" 610" 306" 636" 4'0" 14'0" 12'0" 14'0" 40'0" SECOND-ELOOR PLAN 3/16 = 1-0- 10414 4-9 22'0" 171 9'9" 7T 516" 5'0" 111'6" r ---------11 CDCN, ► - _ ► r----� ' ----------4-------------------- _ 1Li----------- ---------------------- --------------t ►' _ I GARAGE FINISH FOUNDATION I ' All Wood constructed Walls and Ceiling 10" Concrete Wall / 8'0" Pour ; E I to have 5/8" type 'X' Fre Rated " 10" Dp x 1'8" W Cont.Footing Wallboard nsta0ed 2 — 3 1/2 Dia. Lally Columns ►• ; IF I ; With 2'6" x 4'6" x 10 Deep ► ; I ; Footing (1 req'd) 3 — 2 x 12 Center Beam p ' I , 8'0 n f f » 6V6r6» 6'8n 6'8n 6f10» 66n ; o I 3'2" 3'6" ; ' 1 0 �OT T C14 0 v' i I � ; ' ' ' _ � i I 1 •' i C)1 Jarl . A ao r D � I � _T ; � � ; � ; � � � 1 •/ � N CO Cn 4" Concrete Slab BEAM POCKET ; ''• '~ T 6" Wx6" Dpx9" H (1regd) Slope 1/8" per foot - - - Sh'm beam with Steell Shims ►• ; a a or Hard Brick ••• ' I � ' o o m ; 4"(min)Step down into Garage--------' '► ' �- 1 ' tomCO ______-----_ ----------------, 31/2" D'a.Lally Columns With 2'6" Sq. x 1'0" Deep 1 -------------------------------- �► � Footing (9 req d) � ►. ; 0 ------- -----� , 1 — ---=—=--- --' ;-----------------; ; --=—=--- =--:—=--- - 1 L ---------------------------- ►• 11 ► ► ►' r--------------------------- — 16'0" 14'0" ; ,' ►' ; N ►' ,' ; FOUNDATION GENERAL NOTES: s'o" 3'0" 1. Concrete slabs on grade shall have contraction joints with a depth 96 12'0" 14'0" of at least 1/4 the slab thickness.These shall be spaced not more than 30 feet in each direction.Contraction joints shall be placed where 6. Lally column spacing is determined by [ Table 3405-6 pg.34-76 offsets are more than 10 feet . Contraction joints are not required where 6x6--6/6 welded wire fabric 7. Wall pockets:Ends of wood girders entering masonry or concrete walls or equivalent is placed at mid—depth of the slab. [ 3405 .3 .1 .1 ] shall be provided with 1/2" airspace on top,sides and end, unless approved 2. The ultimate compressive strep th of concrete foundations at 28 days durable or treated wood is used [3402 .8 .6 ] shall be not less than 2,000 Ibs.�sq.ft.[ 3402 .2 .1 ] 8. Studs n framed kneewalls shall be 14" minimum n length and when the 3. Foundation walls shall extend at least 8" above f nish rade. kneewall is greater than 4'0" in height,it shall be of the size required 9 for an additional story.Kneewalls shall be thoroughly and effectively [ 3402 .3 . 1 ] cross—braced.[ 3402 .7 & 3402 .7 .1 ] FOUNDATION PLAR 4. The bottom of any point of a foundation shall be a minimum of 4'0" 9. Foundation anchor bolts shall be a m'n'unum of 1/2" in diameter. below finish grade. [3402 . 3 . 4 ] They shall have a minimum embed of 8" in poured concrete. 3/16" = 1'0" 5. The exterior surfaces of masonry foundations enclosing basements shall There shat be a mninum of two anchors per section of sill plate. 10276 5-9 be dampproofed.[ 3402 .6 ] Maximum space shah be 8'0" on center.[ 1704 .8 ] SECTION GENERAL NOTES: Continuous Baffled Ridge Vent 1. Floor design five loads are based on 1st Fir 0 40#/sq. ft, 2nd Fir.® 301 /sq. ft and nonusable attics ® 20#/sq.f . 2x10 Ridge Board Roof design loads are 301 /sq ft fire load and 7#/sq ft dead load. [ 3405 .1 & Table 3406-6 ] 2. Minimum ceing height for habitable rooms is 7'3"-In a room with a 12 sloping ceiiig the prescribed ceiling height is required in only one half _ -- N, _ of the area of the room.No portion of the room measuring less than 5 feet 9 D 1 x 8 CoOar Ties ® 4'0" O.C. finished shall be included in calculating minimum area [ 3401 .6 .1 ]. ROOFING 3. Stairway Headroom:Stairs between 1st & 2nd firs,and 2nd & usable attics shall have a minimum headroom of 6' 8" measured vertical from staff nosing. Composite Roofing " Building Paper Basement stairs shall have a minimum headroom of 6 6". Sheathing [ 3401 .10 .8 ,Fig.3401-1 & 816.2 .2 ] 2 x 8 ® 16" O.C. 4. Frestopping shall be provided to cutoff oil concealed draft openings (both vertical and horizontal) and form an effective fire barrier between stories,and between a top story and the roof space [3403 .2 .7 ] . 5. Insulation minimum total R value requirements for 00000 000000M' Fascia Board Exterior walls is 125,Floor over unheated space is 20D,Roof/ceiling CEILING assemblies is R30,and Finished basements walls is R125.[ Table 3423-1IF ) . 2 x 8 0 16" O.C. 6. A vapor barrier of 1D perm or less shall be installed on the winter warm R30 insulation p C R3or Barrier Overhanging soffit side of walls,ceilings and floors enclosing a conditioned space [3422 .1 ] 1/2" Wallboard. with venting 7. When eave vents are installed,adequate baffling shall be provided -0 o to deflect the rncomng air above the surface of the insulation with a 2 inch minimum clearance under the roof deck [3421 .1 .3 ]. -02 FLOOR o 00 3/4" Sheathing _ j 2x10 ® 160 O.C. WALL Siding,Air Barrier Sheathing,2 x 4 0 16" O.C. R11 knsulatioR Vapor Barrier 1/2" Wallboard ao FLOOR 3/4" Sheathing 2 X 10 ® 16" O.C. R20 insulation SLL 1 - 2x6PT,1 -2x6KD. [3402 .8 .4 ] Continuous Sil Gasket 1/2" Dia.x 12 LAnchor Bolts 3— 2-x 12 Center Beam ® 8'0" OC.(maxi 31/2" Dia.Lally Columns o With 2'6" Sq x 10" Dp Footing (see foundation plan for locctnons) _ FOUNDATION 10" Concrete Wall/8'0" Pour 10"Do Dip x 1'8of W Cor surface ng SECTION THRUHOUSE _ 4" Concrete Slab - Dampproof exterior surface -- -- - -- - - -- - -- - -- - -- - -- - 1/4" = i'0" 10414 6-9 Contnuous Baffled Ridge Vent 2 x 12 Ridge Board 12 8 — 10d Nails 9 per connection (typ) ROOFING Composite Roofng Building Paper Sheathing CEILING 2 x 10 016" O.C. 2 x 8 0 16" D.C. R30 Insulation G R30 Insulation Vapor Barrier Fascia Board 1/2" Wallboard Overhanging soffit with venting 0 CD -ate WALL r— FLOOR Sang,AirBarrier Sheathing,3/4" Sheathing RInsultioR Vapor Bao ier , 2 X 10 0 16" O.C. 1/2" Wallboard ' R20 Insulation -_ r- I I SQL 1 - 2x6PTj - 2x6KD. [ 3402.8 .4 ] 3 — 2 x 12 Center Beam Continuous Sill Gasket GARAGE FINISH 1/2" Dia.x 12" L Anchor Bolts All Wood constructed Walls and Ceiling 31/2" Dia.Lally Columns 0 8'0" O.C.(max to have 5/8" type 'X'Fre Rated With 2'6" Sq x 10" Dp Footing C) Wallboard installed (see foundation plan for locations) 00 FOUNDATION 10" Concrete Wall / 8'0" Pour 10" Dp x 1'8" W Cont.Footing 4" Concrete Slab Dampproof exterior surface FAMILY ROOM GARAGE - SECTION 1/4" = 1'On 10414 7-9. 1 Flush Framed Beam Lower Roof AN members are 2 x 10 0 16' O.C. AN members are 2 x 10 0 16' OP—(URO.) FIRST FLOOR FRAMING SFCOND FLOOR FRAMING 1/8'—i0' 1/8_=1'0' FRAMING GENERAL NOTES: MAXIMUM ALLOWABLE SPANS FOR HEADER SUPPORTING WOOD FRAME WALLS 1. AN structural materials shop be void of any defects that may diminish bier capacity to function in an adequate manner. AN.Span of Headers Structural Engineering or any other professional services that Sim of Wood S�pp�tng One Story Two Stories n Garages or n Walls may be nNuked shall be provided by otters. • Header hoof Above Above not appatng 2 Framng lumber.Spruce—P'ne—Fr.No.2 or better,with a Design Roars or roofs Value in Bending Fb of 1000 for normal duration[Table 3403-30) 3. Wrinum bearing for joist stall be 11/27.[3405.2.4] 2—2 X 4 4' 2-2X6 4'to6' 4' 61to8' 4. Use built—up 2 x 4 posts under all beams(4 miimum). 2-2X8 6'to 8' 4'to 6' 4' 8'to 10' S. Double up floor joist under partition walls above. • 2-2X10 8'to10' 6'to8' Vto6' IV to 12, 2-2X12 10'to 12' 8'to 10' 6'to 8' 12'to 16' 10414 8-9 1z,I Flush Framed Beam - - I • 2 x 10 Hip dt Ridge Rafters(typ) • All members 2 x 8®16' O.C.(UND) M members are 2 x 8 @ 16'OAC.(UNA) ATTIC FLOOR FRAMING ROOF FRAMING 1/8'=1b' 1/8"=1'0' MAXUUM ALLOWABLE SPANS FOR JOISTS f RAFTER SPAN NOTES: JOISTS/RAFTERS 1. Span Tables for.First floor joist[3405-2] EIF Secondfloor& useable attic joist 3405-1n.� tt 13' 14' 15 Attic(no future rooms)[3406-1fCape attic floorjo [3406-2FRST x 8/Yl 2x10/12 Roofs over attics 3406-6x /16 2x10/16 2x10/18 2 x I/6 2x12/16 Cathedral Roof Rafters[3406-3 ] ' TM RM MW COND 2 x 8/16 2 x 180/�16 2 x 10/16 2 x 10/16 2 x�� 2 Maximum span for 2 x 8 ceTrg joist for cape attics is 19'11'[3406-2]. �AioPAWF M 2 x 6/16 2 x 2 x 8/16 2 x 8/16 2 x 8/16 CMM vu at trs 2 x 6/16 2 x 6/6 2 x 6/16 2 x 6/16 2 x 8/16 OVER ATM 2 x 8/16 2 x 8/16 2 xROOF 2 x2 x�/� 2x10/16 2x10/16 CATHEDRAL 2 x 8/16 2 x i 16 2 x,o/,s 2x10/18 2 x 12%12 6 10414 9-9 t JUN L 3 22, /3 7 S.F_ N ol E068" OF � 1aEGln/EA7'�'Q GveTi.�.vD.S o. I G ,1 A o 1 /27.92/ �1 NEPEBY CE.�T/fY TO TiYE'T/TLE/,�/SU.rOT qN0 RG. or 717 G0-.4TE0 OW r11c COT qS'S.SG/Y•V ANO Tiif4T?OAFS 6avllwaeAf IAI ,wlrll OF ee-sv1ArA%v-v AWA4 0/.tai SETEiIG.CS GAT G/•vES." Flo•C.CAv LOG4T O/if/ TNETFE�.4rL ,�CA�pZ•4 OSA.PE oT O.P�i I✓/V FOiP S�/OIvK O/S/i'EM•�f' L'OMM�/�v/TY P.4.VGL '� � OF QATQ� i�2�93 . /"7 $ HO NN '09#36381 E",v6�WEE.Pili6 SE.PI��CES A�VOO/�ET �J.4S.£4G�Yl/SE1T.S O/B/O Location ` Com--. No. -v Date NaRTM TOWN OF NORTH ANDOVER + ; ; Certificate of Occupancy $ s+cHus9 '•'a Building/Frame/Frame Permit Fee $ s t Foundation Permit Fee $ t Other Permit Fee $ TOTAL Check # Building Inspector r u ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING �q BUILDING PERMIT NUMBER. DATE ISSUED: _ 9_ Q cf M SIGNATURE: Building Commissioner/Inspector of Buildings Date z SECTION 1-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: (0 X14 1gnC+tA, A, ��3 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: / Public ❑ Private ❑ Zone Outside Flood Zone 11Municipal ❑ On Site Disposal System 4. SECTION 2-PROPERTY OWNERSHENAUTHORIZED AGENT Ristoric District: Yes No M 2.1 Owner of Record Q alru s /= (3-e vc vc eJ� G Name(P ,nt) Address for Service (7� 2 S� Signature Telephone 2.2 Owner of Record: Name Print Address for Service: z M Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name I'1 Registration Number rM Address Expiration Date G) Signature Telephone U� SECTION 4-WORKERS COMPENSATION(M.G.L.C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes.......❑ No.......❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ PAlterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFF14CIAL USE ONLY Completed by permit applicant 1. Building � (a) Building Permit Fee DILVMultiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)X(b) 4 Mechanical HVAC �Q 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT t I, 6? L as Owner/Authorized Agent of subject property ereby alithorize to act on M alf,in all matter rel ive to work auth ' ed by this building permit application. i ature of Owner Date ?�T� SECTION 7b OWNER/AUTHORIZED AGENT DECeLLA_RATION I, ZT7 as Owner/Authorized Agent of subject t property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belie 1 S Vr � e - Pr� t e i ature of Owner/A ent Date t NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TUVMERS iST 2 ND 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 �N,Sl t &J S t L, l/+ r 6 — s ,_Coy FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLIICANT FILLS OUT THIS SECTION************************ APPLICANT flv G�� L= !/1 til ! PHON a 2 S'� LOCATION: Assessor's Map Number PARCEL SUBDIVISION / Q LOT (S) STREET f/O�i( �l ST. NUMBER—&�J USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOO=CTOR-HEALTH DATE APPROVED DATE REJECTED S I CTOR-HE TH DATE APPROVED E� DATE REJECTED COMMENTS PUBLIC WORKS -SEWERMATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm KORTPI D Town of North Andover' Building Department it o ., p 27 Charles Street North Andover' MA. 01845 �sSacwuye< D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print. C A DATE JOB LOCATION Number Street Address Map/lot Al 9 "HOMEOWNER `��?�L re-i K G2 �i� l Name Home Phone Work Phone PRESENT MAILING ADDRESS 009-1–f (-J( City Town l State Zip Code The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner'certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Unheated 3 Season Porch BASEMENT Roc Room Garage Utilities Glaset FIRST FLOOR Deck JJ� �I Jl Kitchen EG Pantry Den fr Living Room Dining Roam Closet �' Closet .41 1 Closet Bedroomno na Closet r Beci room Bedroom Bedroom SECOND FLOOR t4ORTfi Town of 6Andover No. LAK A. dover, Mass., LV COC ICHEWICK RATED�qs I"? r� U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT... a jva% 3 Z BUILDING INSPECTOR ................................................................................................. ... Foundation has permission to erect..-r1A.13h........... buildings on....AA.....CO Al A.0 .....................&...........A..Wk........ Rough AS�to be occupied as..... Sj.:j1q&.....FAM.1.)y.......&# S S................. Chimney ........ ............... . ................. c provided that the person accepting this permit shall in every respe conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws elatin to the Inspectio Alteration and Construction of Buildings In the Town of North Andover. j'0 � Now 0?804 q 91 -Wvo PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR 0 Rough ..................................... .......AP10-0111014; ...............A......6---'� 04 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. SEE REVERSE SIDE Smoke Det. • CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number Date /( THIS CERTIFIES THAT THE BUILDING LOCATED ON e Ce /n- �N 4 AV MAY BE OCCUPIED AS .S N GL4-- - IN ACCORDANCE I WITH THE PROVISIONS-QF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. MORTM 1 ( CERTIFICATE ISSUED TO Q (Z S � L '00 ADDRESS _ 4-A).D d 2 � • s SACHUS But ing 1 pector � �IORT Town ofover No. X1 9 9� * over, Mass., LANE ,� A_COCH CHEW ICK`yY�• 9S A4 T E 0P� (� BOARD OF HEALTH Food/Kitchen PERMIT T Septic System /J *' , r ` BUILDING INSPECTOR A THISCERTIFIES THAT........................... ............. ..4�.. ....I...L.rl.. Ae....S....................................... Foundation has permission to erect............ C.�l .................... buildings on ......... ... ......... o. ..1 ... ......... U. ou l c3 tobe occupied as.................................................. �1�...6. .. ............... 1.... .... provided that the person accepting this permit shall in every respect conform to the terms o ie application on file in tna 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 INTEC'TOR VIOLATION of the Zoning or Building Regulations Voids this Permit. uu 47/3 Fi O L ", f< PERMIT EXPIRES IN 6 MONTHS ELECTRICAL SP UNLESS CONSTRUCTION STARTS ............................0................. ..... .... .. tlJ B D G SPEC'TOR �� �-- Occupancy Permit Required to Occupy Building - GAS INSP R Rough , Display in a Conspicuous Place on the Premises — Do Not Remove final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT s Until Inspected and Approved by the Building Inspector. Bumer— Qr /��N Street Nor— c•(c. !/�' • Smoke Let. Location No. Date NORT►, TOWN OF NORTH ANDOVER „ Certificate of Occupancy $ �5 ` Building/Frame Permit Fee $ �ss�cMusEt Foundation Permit Fee $ � — Other Permit Fee $ g Sewer Connection Fee $ ? Water Connection Fee $ TOTAL $ Buil fig Inspector Div. Public Works PERMIT NO. APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. LOT NO. JV2 RECORD OF OWNERSHIP IDATE BOOK :PAGE ZONE �- SUB DIV. LOT N0. g LOCATION ClYr'()UZ PURPOSE OF BUILDING OWNER'S NAME �J „/ „�c NO. OF STORIES OWNER'S ADDRESS 'K BASEMENT OR SLAB ARCHITECT'S NAME,/1 /T 1/C„ �'0// SIZE OF FLOOR TIMBERS IST nx/6 2ND V`/O 3!2?,< BUILDER'S NAME /� �ICC. SPAN Of i?[ J DISTANCE TO NEAREST BUILDING1/iy DIMENSIONS OF SILLS• Al o --- DISTANCE FROM STREET /tO/' O�! "' POSTS DISTANCE FROM LOT LINES-SIDES `IO I� D d REAR nit s1� " GIRDERS A,,) AREA OF LOT aa,3 y u FRONTAGE bI'IJV 117 HEIGHT OF FOUNDATION( l / _cJC® THICKNESS IS BUILDING NEW `e-s [71 SIZE OF FOOTING 6o y��i X IS BUILDING ADDITION ! y I�, MATERIAL OF CHIMNEY (!�Xe7lrmvoe v IS BUILDING ALTERATION `,& IS BUILDING ON SOLID OR FILLED LAND Svi, WILL BUILDING CONFORM TO REQUIREMENTS OF CODE V� IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY 7 IS BUILDING CONNECTED TO TOWN SEWER k)O IS BUILDING CONNECTED TO NATURAL GAS LINE /1)b INSTRUCTIONS 3 PROPERTY INFORMATION D � LAND COST SEE BOTH SIDES " EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. 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 FI < SUILDING INSPECTOR 810 ATURE OF OWNER OR AUTHORIZED AGENT F E E OWNERTEL.N PER! ! BLDG. T PERMIT GRANTED 1 �. r.. �_ �/ CONTR.TEL.# �19 LESS FDA ;L_ ___1a c7 DUE FRAML PERMIT$ CONTR.LIC.# ,0,/ H.I.C.>Y - BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY srORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY _ OFFICES _ LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS I I RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ 3 1 2 3 CONCRETE BL'K. PINE BRICK OR STONE HARDW D _ PIERS PLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. 8 M AREA _ '/, 1/1 1/1 FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW 0 ASBESTOS SIDING _ COMMCN _ VERT. SIDING ASPH.TILE STUCCO ON MASONRY _ STUCCO ON FRAME B I N MMONRY ATTIC STRS. & FLOOR I_ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR II POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH 13 FIX.) GAMBRELMANSARD TOILET RM. 12 FIX.) FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADo jj� 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. &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 lit 13rd 11 NO HEATING �.►OR'r Town of over No. . ----= _ * _ dover, Mass., X19 LAKE •' w 9�-COCMICNE MACK LY 7• S TLC p I•PP �� rG BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System l BUILDING INSPECTOR THISCERTIFIES THAT...........................At....C. ...............a.u.1....I....D..Fit...5....................................... Foundation has permission to erect............ -.................... buildings on.........�?..�. C.10.10J0..0444...I Ad9 Rough to be occupied as...........................................1�4 ..6.,C 6.46............... etmr;sz.. .... ................................ Chimney provided that the person accepting this permit shall in every respect conform to�ie application on file in Final this office, and to the provisions of the Codes and By-Laws relating,to the..lnspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL nvsPEG"TOR Rough .............................................. .... Service ... . .... ....... .. .................... B D G SPECTOR 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. PE1ImR YO._____�y� APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER MA MAP (VO. /Q . SS. PAGE 1 LOT NO. �^ 2 RECORD OF OWNERSHIP (DATE ZONE � "---� �"�D�//�I �✓ G BOOK ;PAGE SUB DIV. LOT NO. �I LOCATION �O/O/t/4/ I L+ C PURPOSE OF BUILDING OWNER'S NAM[ NO. OF STORIES SIZE OWNERS ADORES f r / / / BASEMENT OR SLAB ARCHIT[GT'S NAM[ A��« �A�CIQQII SIZE OF FLOOR TIMBERS 1ST SUtLDtR S A NAME SPAN /l' �X�6 2N D X Al ,y O,l.` �l OFITA ICE TO NEAREST BUILDING 1��/ �/ -- G -7' DISTDIMENSIONS OF SILLS __ax ICE FROM STREET O� DISTANCE FROM LOT LINES POSTS AREA OF LOT SIDES ry 7 - C r h (.XQl/ REAR f�l �r GIRDERS k (I _, FRONTAGE �( �!/�' HEtGMT OF FOUNDATIONf'17 _ f THICKNESS IS BUILDING NEW �/ /�' V L/ /Cs SIZE OF FOOTING 0 x/� X IS BUILDING ADDITION �d MATER:AL OF CHIMNEY ,I I IS BUILDING ALTERATION /CIO IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODEV yCo� 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 SEE BOTH BIDES LAND COST PAGE f FILL OUT SECTIONS1 - 3 EST. BLDG. COST . F PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER SQT. EST. BLDG. COST PER ROOM ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS '4 APPROVED BY PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FI BIO ATURE OF OWNER OR AUTHORIZED AGENT BUILDING INSPECTOR FEE �+ OWNER TEL.x PERMIT GRANTED BLDG. PER�?'��; �T� �_ �� CONTR.TEL# 19 LESS F^ 0 _ DUE F'irii�ii� rtrtivli I CONTR.LIC.# _DI�dFr H.I.C.# OPE1 i SPAC. /V ` .1 S84,32'52"E 126.,37 N y5o in OPEN ,49.E SPACE \ O / ' r 586'51'2 - 10,3.J4 9 28 A.C. B U I L D F_ 11�1C p � A � 13 '7 � SCALE• 1 " = 40 ' 0'-z4: T-o9*1 svaso�L- o"-Z4" Tb? SutSok.. S«T,( SNfko Z4"- 1Z4� GLAC,T,4` W� Sov\-VE�Ll W� Sou.,-oCt's -�\ ,- 101' c I 1A PN \3Z'" 0 \43.a 147- To f- 42ToP rt. )-' WeLLC� = IS(o,6 FORM U - LOT RELEASE FORK 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: A I n c, Phone 0 5-8 3 5 0 LOCATION: Ass essor's Map Number Parcel Subdivision 1QAJ ES�fLAf tS Lot(s) al Street Co 1011 i a I n Jc. St. Number E� ************************O ficial Use Only************************ RES O WN ENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector--H-ealth Date Rejected Date Approved d2 / Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connections -97 - driveway permit 2 - 4 - �7 Fire Department eLzy&t�lloo� Received by Building Inspector Date iia 69 ' APPLICATION FOR WATER SERVICE CONNECTION -Y North Andover, Mass. T' 19 Application by the undersigned is hereby made to connect with the town water main in rck4". 4 I 26 L Street, subject to the rules and regulations of the Division of Public Works. Ale The premises are known as No. ' �IV�I<<r 1 Street or subdivision lot no. U� jSfJ Owner Address Contractor Address Y'' ',--Ts` _� ptica is Sign re PERMIT TO CONNECT WITH WATER,I AIN The Board of Public Works hereby grants permission to to make a connection with the water main at C C` GStreet subject to the rules and regulations of the Division of Public Works. oarq of Pubrlic Works By Inspected by Date See back for rules and regulations RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be V type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal Fi 15202 Corporations 1-1 15212 Curb stops Fi 15402 Three part unions Fi 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 4�/s foot rod and brass plug type cover. TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET. 01845 • GEORGE PERNA Telephone(508)685-0950 DIRECTOR Fax(508)688-9573 f NORTH e 32 h, 'c OL O to A # 1 h # 4rE c,'°P`�c 9SSACHUSEt DRIVEWAY PERMIT Date: q 7 LOCATION: BUILDER: phone: OWNER: phone: 6'95 ? 550 The North Andover Superintendent of Highway Utilities&Operations MUST be notified of the grade and set-back from street established in any driveway entry onto any street or way maintained by the TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval of such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT. Remarks: Approval: JUN 2 3 20, /3 7 O��/+NEA7'E'D u/CTu1.vOS o G ,1 flA� FQ,��sg,18 � � r I III O � � 1 "S .S/EPEBY CE.cT/FY 727 T,Y.-T/TLE/,dSC-WIC 400 7V THEB,O,V&XWT LGCATEO ON TiVE L4T.f.f.S,fVWAI A,VO ;iA"r/T 04CS G'av oaew /N ( 9-9 !Y/7N 7�S/E�D�,✓ OF 410 Avoo✓re 2p,V/w6 zeave.4news ,fw&4.e0/,ICK' SETQ.I�it'S ozo-V ST.t'EETS �T LlvE.S."' /-v• LOG4T p/A / TNETFE AG A.1000�ZW4 O A.PE r OiP,'�IH�/V FOiP syaN/K 0/V le^404' COM,aIt/N/Ty PMAIeZ ow'� D A'TED i�2�98 J S P•L.S A47-e HCO N 9 #36381 , -� i1lE.P.P/�tl.9Gt'E',v6.WEE•�/,v6 SE.P/�/CES ANOOYE� W,4X£ kZo00/.SETT.S O/8/O A � Date........ .....: .� .......... 1 NORTI� 6 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SSAtMUSE� / This certifies that ... ! r ................................................ ...................r........... has permission to perform .'S�'�✓j('r't w•�! �'`' wiring in the building offf....... a/..rt..`/ << ................................................. fP.. .......1 ............... .North Andover,Mass. Lic Nei/ � // .,�....s..,...l..r....................... ir GELECTRICALINSPECTOR —heck # �U i7 The Commonwealth of Massachusetts °"ice Use Only � •� rerctt Department o/RELAl" ty ,Occupancy i Fee Checked BOARD OF FIRE PREVENTIIONS S27 CMR 1200 3/90 (leave blank) APPLICATION FOR PE PERFORM ELECTRICAL WORK All work to be performed In a he Massachusetts Electrical Code.527 CMR 12:00 (PLEASE PRINT IN INR OR TYPETION) DateCity or Town of zi _ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 6 C Q „gL f Owner or Tenant_ P,C,'Iw,' Owner's Address Is this permit in conjunction with a building permit: Yes �No ❑ (Check Appropriate Box) Purpose of Building_',./,,,,S/1 Utility Authorization NO. Existing Service 00 Amps J,>0 / .;y 0 Volts Overhead ❑ Undgrd❑--No. of Meters_ New Service a Amps ,C _ /y Volts Overhead ❑ Undgrd❑ No. of Meters e Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work,, 4L� b c.� No. of Lighting outlets a No. of Hot Tubs No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑grnd. ❑ Generators KVA No. of Receptacle outlets 0 No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total No. of Detection and tons Initiating Devices No. of DisposalsNo. of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑Municipal [:]Other No. of Connection No. of Water Heaters Si�nsf Ballasts Low ng Voltage No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES❑ NO[] I have submitted valid proof of same to this office. YES❑ NO If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE Q BOND ❑ OTHER n, (Please Specify) General Liability 12/31 /04 Expiration Date Estimated Value of Electrical Work S Work to Start a Inspection Date Requested: Rough Final -5124JO Signed under the penalties of perjury: FIRM SKIM Boissonneault Electric Corp. LIC. No.Al 1823 Licensee l��1/��, i �5p�s pY�,-, . ; Signature__/�z LIC. NO. LQU Address 19 Chuck Drive, Unit #6, Dracut, MA Bus. Tel. No. (978)454-0183 01876-Alt- Tel-OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage o$o itssub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Ida, Signature of Owner or AgentAle � ( � � a Date........ ....�................ NORTF" .�,+ o? o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSACHUS� 01 This certifies that ✓-�...... �t �f` � �......... ...... .......... has permission to pe orm C ///� wiring in the Ouil ing of'.....:: . 3. ............................................ at......................................:ti.. :....(.��..r........,North Andover,Mass. " J� Fee.... .../........... Lic.No. .........: ?4�........................................................ ELECTRICAL INSPECTOR � Check # •� �---� ,.J f � Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ::�J 15 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Revof't�) . 11/99] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 MR 12 0 (PLEASE PRINT IN INK O )JAE4INF RMATION) Date: City or Town of: ��rTo the Inspector of Wi es: By this application the undersigned gives n *ce his or her intent' to perform the electrical work described below. Location(Street& tuber) Owner or Tenant Telephone No. – Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No EV (Check Appropriate Box) Purpose of Building Utility Authorization No. Existim,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: Installation of Security system Completion o the followin table may be waived by the Inspector qf Wires. No.of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA BAbove ❑ In- ❑ o.o Emergency Lighting No.of Lighting Fixtures Swimming Pool rnd. rnd. attery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o eteD and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number TonsKW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems: No.of Devices or E uivaleneC l No.of Water KWo.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. a H dromassae Bathtubs No.of Motors Total HP Telecommunications Wiring: Hydromassage No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical rk: — (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under th pains andpenalties ofperjury,that the information on this application is true and complete. FIRM NAME: ty LIC.NO.: 1 r,3Ir Licensee: John S. Bassett Signature VAJI LIC.No.: 1533C 10 (Ifapplicable,enter"exempt"in the license number line.) (7 Bus.Tel.No.: 608 594 5928 Address: Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Li*see see does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ . Date. S. . : .1.'. . . . : 01 .4 0 °TM,1'p TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSf This certifies that . . . . . . . . . . . . . has permission to perform . . . . . . . . . . plumbing in the buildings of . . . ;'. . `. �' . . . . . . . . . . . . . . . . . . . . . at . . .. !. . . . . . . . . . . . . . . !. . . . . . .�. . . . . . . . ., North Andover, Mass. r Fee 1 , . . .Lic. No.l. . '.'. . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # S , 3 ' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,M��AC,NSETTS �j� �i a �� //rr Date Building Location U l� /�/ 'Owners Name Permit# / Amount Type of Occupancy S/� (f New Renovation Replacement Plans Submitted Yes No ❑ FIXTURES E~ 3U w Cn � � Cn w w x w z a a x a En x a a a 3 Ems. W '" ;;4 A A z z SW-BRM BASENM r it" zl`la IOOR An FLOOR 4MHDM SM HA" 6M I LOOR 7M H1" gm HDD (Print or type) t Check o rtificate Installing Company Name 7alcac orp. Address �r rl Partner. Business Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the of insurance overage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ 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 Stat Phu i Code d Chapter 142 of the General Laws. Gl/�ZZ/�. By igna ure oure o ice�u erer Tpe of Plumbing License Title City/Town icense iNumoer Master 131- Journeyman ❑ APPROVED(OMCE USE ONLY