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HomeMy WebLinkAboutMiscellaneous - 68 RIDGE WAY 4/30/2018 6868 RIDGE WAY 210/098.=_5-0000.0 i y� � �� �� � D Y`< ic--_ �(�S. ���a� �_�/` �� S Location '68 No. 050 Date NORTH TOWN OF NORTH ANDOVER h? • • 0- + Certificate of Occupancy $ cMus Building/Frame Permit Fee $ s� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check # 1 3 6 3 0 Building Inspector { TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING M BUILDING PERMIT NUMBER: 6,5 D DATE ISSUED: Q110)0?oo 6 X SIGNATURE: Building Commissionefflfor of Buildings Date CZ/ 0 C) z SECTION'l-SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 0 500b4&64 (� S jo— *7600' WAYMap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage(R) 1.6 BUILDING SETBACKS(ft) Front Yard 17(A, Side Yard N/A Rear Yard "/A Required Provide Required Provided Required Provided 1.7 Water1.5. Flood Zone Information: N A 1.8 Sewerage Disposal System: > Public )rply M.G.I,C.40. 54) Private , 0 Zone Outside Flood Zone 0 municipal K On Site Disposal System 0 SEC ON 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1 Owner of Record FA:Tj2-((�+ LA-094- Wk\1-rE— (7A V V1 g4i -7-6m. Name(Print) Address for Service Signature Telephone 2.2 OwncV Record: Name Print Address for Service: 0 Z M Signature Telephone 90 SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 lnl 1. AJDA-J I Licensed Construction Supervisor: 0 ?p 61 Spr�f� License Number mn Address q 15 1 & > "7�Lkc-� i Akft— —Expiratior Date ic Signature Telephone 3.2 Registered Home ImpAcmd'k Contractor Not Applicable 0 t'A)I C'fl(67,-, Company NameM Registration Number r Address' R-Q(, SA-LEM r-7 11 -51 T7 if-G?q Expiration Date Signature Telephone J 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 buildipg permit. Signed affidavit Attached Yes....... No.......0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ 'r Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed dWork: ' SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be . OFFICIAL.USE ONLY Completed by permit applicant •. =l 1. Building _ (a) Building Pernut Fee Multiplier 2 Electrical (b) Estimated Total Cost of 0(J Construction 3 Plumbing Building Permit fee(a)X (b) 4 Mechanical HVAC C'7- 5 Z5 Fire Protection b Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, wla2/lzt( -J—, 2dmoa=J as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name -g-© a Si ature of Owner/A ent Date gill NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST2ND3 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 - Lt/1-dyrtE z�6` I t�0 PL14N: ��C 23l.L 5 I ELEc, qo.�6 vNiPitits ' I `4 d 3o KNEE WALL I w i rN Re-vo macE Q` �/ Ao46 rOf' v H���i� i(L-Z. DooRS I 0 5 j(W ACCeM I Dooa, F.6 T i1Sov,- XNEE WAS !N j04cic w4l, < �1jlsT�NCr � � soF��r AREAS ft Ho"Y " oC '�tRoUb�r AR�fI- p� 0 W�z i `-1 h�!t>LhDcr woFtV% � 13 � Wa�IKN EX!3 ri N!r� I C�RPEr/N(T FjvKK i4JR0wD I �Ro�Crs+�T E)vsnnvd I u 1064 304 EsCtsrik�- U -r t L ► Ty FoYeft I LxisnNfr 3-CAR 6AKA6,1E �- ,dations Board of.. ac, I ► �e ro 13 Bo ►0" Pea = ,, one p s�ll��:; _ 1,018 geg�Q�►,:S`�"ia,021 08 Birthdate: 1011511959 1J SUPER`�ISOR LICENSE Restricted To: 00 i License: C0N5TR0CTlO 050281 Exixre�: 1011512Ga�= Number: CS _ M1 ZANNONI . t WILL $06 SAL.EI`'i RD 38'r 1 of address notificaticn. 4 DRACV'r MA 0]326 Tr.no: tand change ; Keep top fpr receip 4 _ _ ,_ - - iy`�ix- ,.;pry �• . to r 0711tv - i1 t, ' �. � �`°'� a Wlli� ]. j�wf+o�i+ Inc. Y •� 0mett:ll A 01826 r x A a The Commonwealth of Massac,�use!ts Department of Industn�lcc,�ents GF,ice cr Investicatiens Eoston, Mass. 02111 ✓Ilcrkers' Comcensadon Insure;ce AT'davr Flame r lease r::nt i Name: LCcZ-ticn: Cit/ nccre I an, a hcmecwrer per erring all work myself. �j I am a scie crc.rieter 2,-,d 'nave no one 'ticrkina in any c_-eaC; J I am an em.dcyer zrcvidina workers' ccmpen-s_aticn for my emplcyees we xinc cn is JCC. CCmcary nc P' V✓ " cj(/�/y�� �- c /VtFr 0L� p hCrP =. 7 7 O ff - ,34- Insur,;rc- CO. �� vt2` �73¢��t P^lici �f�4g77 i Ccmc2nv nerve: Address CiN hone r Insur2nc- Cc. F�lici = Failure to sec:;re ccverace as recu;rec ureer Sz::en 2`A cr,MC-L I K can Ieae to the;mcos iicn a cnmir.21 Pen aities cr a rice up to S .°CC.CC anc'cr one years'imcrscrrr:e.^.t as .veil as c:vi penalties in :he rcrm cr a S CF'PJCRK CRCEF.and a:ane_; ;CC.CC) a cay ;airs me. I uncerstanc that siaiert e.^.t,Tay ce forN2rcec is the Cffic2 cr Invesccaticns cf:he CIA..,cr ccverace verirc� cr. 1 do herecy cererl under:he:a,hs and.�enaltieS or per Jur!char'he inrcrmadcn rev ded accve's'r e and ccrrec:. Sicnature r2t= Print n2me F;,cne 1 G`io:al use envy cc net wme n this area ,e ce ccmGetec oy c:,,,/Cr cr i avn F-rm;tll.:czns;r.c Cay - Eulidinc Dept iirnmediate resCcrse is recuired C L.'COnsinC Ecard r, seiec:,;�an's Cr,""ice C nrc:vers ehcre r- eeltn Decarment BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54,a condition of Building Permit Number 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 Si tore f Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector e • NORTH Town ofC E R Andover 0 No. Y = LAO lover, Mass. f �v� COCMICHEWICK ' ' ADRATED FPPa�,�S S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT.....?AJ*Y!--1k--*...Ab..o-P-h..............�G /..A �'�. /��� 1yA BUILDING INSPECTOR has permission to erect....4 /..45h...... buildings on ...... .. ........ ...... ............................. .................... • ug; to be occupied as...... .���. y`'...... r ......RI�S/ !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 g PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR M,t UNLESS CONSTRUCTI ST TS �► • Rough M %0Ok • ............................. Service 4BUILDING INSPECTOR �� Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT Street No. SEE REVERSE SIDE Smoke Det. .� .+.wvw•iv.��r iQ u"irumra ^rruLoAfium run t'CSimii iu Liu TLumusul i (Print or Typei NORTH ANDOVER, , Maas. Date 10 BuOdin Permit ° J Location Ones ` Name New Renovatlon ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ w ! >t » rM >i J re >~ V < M ! e1 < t"31 v WLL 0 P a: J M M M = + F U s • 1t < M 06 L M u = 0 7 t • r s ! < y ; r < O o 06 F� rJ f H O M (. at a O ! _! � 0 K �rCel M- 3 � 1 • • o o � It s ►• w �' o a 4 < It s • o tUa—faYT. fAttlY�NT 18T FLOOR IND FLOOR SAO FLOOR 4TH FLOOR ITH FLOOR ITH FLOOR, ITH FLOOR ITHFL004 — Check one: CertWIcate Installing Company Name ❑Corp, Address i26 $-Partnership ❑Firm/Co. Business Telephone •Name d Licensed Plumber INSURANCE COVERAGE: ec one I have a current liability Insurance policy or As substantW equlvatent. YesX No ❑ It you have checked y", please Indicate the type coverage by checking the appropriate box A Itablilty Insurance pollcy ❑ Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the itcensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on Chia permit application waives this requirement. Check one: slon ❑ slurs of Ownu a ONmer s Agent Owner ❑ Agent I hereby cerUty that all of the details and Information I have submitted for entered)in above us trw.a4axwato to the best of my knowfedge and that sit plumbing wait and Installations performed under the permit ILuAd for applkatlon Mn pertinent provisions of the Massachusetts State Piunbinq Code and Chapter 142 of �mpflana�� By , Signattx*061 Title l City/Town license Numb« Type of Plurnbing 1Jcsnse: Master APPfXWED(OFFICE USE ONLY Journeyman 0 ` Date. p'<".0.':��o TOWN OF NORTH ANDOVER A PERMIT FOR PLUMBING N ,SSACMUS� � f This certifies that . . .. . . . .�.(I. . . . . . . . . . . f. . . . . . . . . . . . . . . . . . . . has permission to perform . . . . —. . . . . . . . . . . . . . . ' N plumbing in the buildings of . . . . 0 . . . . . . . . . . . . . . at. . . .,.:. . . ; . . . .r. orth Andover, Mass. Fee.:.'. .'- Lic. No./i. sf?. 2 . . . . , . . . . ' . . . . . . . . PLUMBING IN CTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Location No.if Date - 1 -T-�. __ LCJ , TOWN OF NORTH ANDOVER a Certificate of Occupancy $ s • ' * > ; • Building/Frame Permit Fee $ �ssAGMUStt Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL $ `f Building inspector 10/24/95 12:50 i59.0 PAID - -- -- " Div.Public Works Location No. Date t ra NaR,h TOWN OF NORTH ANDOVER ' �p Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Zi 22.09 to 7 Water Connection Fee $ /6/, 00 00 o TOTAL �Z S S rYLh� _,i�il i In or h- 9152 ulKic works PER11IT NO.�� !�� APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MAP +JO. _�I LOT NO. 4Y>o� 12 , RECORD OF OWNERSHIP (DATE BOOK ;PAGE — ZONE le I SUB DIV. LOT NO.�,� 4 LOCATION /� Lam, /� � / t _ _� PURPOSE OF BUILDING OWNER'S NAME �a�o,IAS /�L^//h".4 /s /llz 19 ArX I NO. OF STORIES az SIZE OO �� OWNER'S ADDRESS ��`�» M14� eioL /NC py/.[j�lp� BASEMENT OR SLAB ARCHITECT'S NAME � //rrS h'Y SIZE OF FLOOR TIMBERS 1ST.jX mT 2ND �K/b 3RD b T/1 BUILDER'S NAMEo /�✓S SPAN �.5.. / -- DISTANCE TO NEAREST BUILDING 3P DIMENSIONS OF-SILLS DISTANCE FROM STREET POSTS 7o/'w or DISTANCE FROM LOT LINES -SIDES r n REAR /tD GIRDERS , /'py /p AREA OF LOT �1� JXy7 et FRONTAGE !/✓�O HEIGHT OF FOUNDATION I pN/O O THICKNESS /� eel IS BUILDING NEW v�/�J�. SIZE OF FOOTING /, dyO X /O 'j IS BUILDING ADDITI N i/' MATERIAL OF CHIMNEY / OCp IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND O WILL BUILDING CONFORM TO REQUIREMENTS OF CODE rS IS BUILDING CONNECTED TO TOWN WATER ✓ s r BOARD OF APPEALS ACTION, IF ANY w//nY IS BUILDING CONNECTED TO TOWN SEWER yr 5 IS BUILDING CONNECTED TO NATURAL GAS LINE Yom. INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES CCYYCw EST. BLDG. COST A i LJ F r COST PER SQ BLDG. . . PAGE i FILL OUT SECTIONS 1 - 3 EST. j 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 e ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED MYILDINO INSr[CTOR SIGNATURE OF OWNER OR AUTHORIZE AG NT F E E OWNER TEL.# 401�-G�.,7' 70 PERMIT GRANTED tc" -.j CONTR.TEL.# r 19 76 E .lC�' �O - CONTR.LIC.# CS o5/3�aj 06 two a H.I.C.# t �S BUILDING RECORD 1 OCCUPANCY 12 y SINGLE FAMILYsroRlEs THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY o1FICEs LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE d 1 2 13 CONCRETE BL K. PINE _ BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T' AREA '/. 1/1 V. FIN. ATTIC AREA N_O 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 MfAC _ ASBESTOS SIDING HAHARDVV D VERT. SIDING ASPH. TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR (- BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) • GAMBREL _ MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING - TAR 3 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. b COLS. STEAM akin STEEL BMS. & COLS. HOT W'T'R OR VAPOR AdM WOOD RAFTERS AIR CONDITIONING RADIANT H' I UNIT HEATERSRS GAS 7 NO. OF ROOMS !OIL B'M-T 2nd I ELECTRIC lst 13rd I NO HEATING It NORTFI To" ' of . �� � Andover O it '° ; No. a �? dover, Mass. 19?6 O - 'AKE 1, CoC RICHE WICK ORATED 4 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System O BUILDING INSPECTOR THIS CERTIFIES THAT........................ / ..5/., (` �d ..........w6.0....47... ........ •r ........0...4l��.+ Foundation has permission to erect............................. building.on ..............1 .8....../....�..1�..4`�..��.�...�..4..y...... Rough to be occupied as ..............................................' /..J .�. f ........... 11.E�L. ./...........................................r............ Chimney provided that the person accepting this permit shall in every respect conform to thf�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 ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST Rough Service BUI IN 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 Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. Smoke Det. 1 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, regulation's or requirements. ************,,**/***App>>licant fills out this section***************** APPLICANT: f�rt2sin��"on ��a��f'� 1,�c,> �e�rr� ,�i.1 PhoneOc�' ��'�•�2999 LOCATION: Assessor' s Map Number Parcel Subdivision Lot(s) -'/eP Street CJ&1A / St. Number C� s ********************* **Official Use Only************************ RECO 'NDA ION F OWN AGENTS: Date Approved Conservation Adi6inistrator Date Rejected Comments Date Approved own Planner Date Rejected Comments / Date Approved V Food Inspector- a h Date Rejected Date Approved L/ Septic Inspector-Health Date Rejected c/ Comments Public Works - sewer/water connections - driveway permit Fire Department JF Received by Building Inspector Date a5� � U v e 1 IE 1• � LOT 48A 1 22,093 S.F. 1 \ •1 J 47A 1 i S.F. 0 1 1 Q 1490 \ N 11 \ \ to 380 J76 o ISI a ` Qs0'LA ---�_- 0 360 \ � 1 PROP. DRIVEWAY • TOTAL P.02 a VkORT T ►y oNvn. of 4Andover0 No. = �A E dover, Mass., 19� COCHICHEwICK �1. �ADRATE D PPa\ '9S BOARD OF HEALTH PERM .IT T D, Food/Kitchen Septic System ON B NG INSPECTOR THIS CERTIFIES THAT........................ . ,14�w��.�I�.6ya.A)..........c ..:�...T........ r .......h. �� oundati haS oriiiia'iaon to erect.............�--.—.......... buildingt.on .. .f ... . p 2f A—A...... .. Tr.. 4r.w.r......T. .K ...... xough < tobe occu� Fad as.............................................. /..JS<. ............ t .F.. . ./....................................................... Chimney provided that the person accepting this permit shall in every respect conform to thb 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 hermit. Rough PERMIT E)TIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST Rough .................................... .... ...... .... ..... ........ .................................. Service BUI ING 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. C`� 6 a', CERTIFICATE OF-USE & OCCUPANCY Town of North Andover Building Permit Number `�73 Date (.7 THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSE STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. MORTq o',.• • ..'y CERTIFICATE ISSUED TO ZZ7, au t© 0 F 4 ADDRESS Cc. O+,ire� '(� '..� '•SACMUsc� BuAding Inspector XAORTH Town of 4Andover No. 0 �; T 0 �A E dover, Mass., 19,96 � q COC HICHEWICK „p °RATED PPS Cl 7 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System • 0 G INSPECTOR THIS CERTIFIES THAT S/,rte B oundati �!4S. has permission to erect........................................ buildingt on .............. j. .... . ..1�..4�..��. ... .. ...... Rou to be occupied as y 5� .( ..�I ........... As�. . ... ........................................................ Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in i`4 ? 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. PLUMB GIN PECTO VIOLATION of the Zoning or Building Regulations Voids this Permit. o `? d�p 7 � PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION ST ELECTRIC PE R ou 3 �7 .................................... .... ...... ... ..... ........ .................................. Service BUI ING INSPECTOR v Occupancy Permit Required to Occupy Building GAS IN ECTOR��y Display in a Conspicuous Place on the Premises — Do Not Remove °u '�� y No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. K • Ga;OPiping • Power Burners • Water Heaters • Boilers • Furnaces • Sales&Service MARK BURKE PLUMBING AND HEATING COMMERCIAL,RESIDENTIAL 8 INDUSTRIAL (978) 372-7272 Mark M.Burke Sr. Master Lic.#318 NH 272 Kenoza Street Journeyman Lic.#18717 MA Haverhill,MA 01830 .. Date:J.-. sr ' 3765 NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING cmus� This certifies tha .�. . . . . . . . . . . . -' . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . ... . . . . . . . . . . . . . . . . . . . . . . at. 1/?. . . . . . ., , North Andover, Mass. Fee . . . .Lic. No.,/A/ PLUMBING INSPECTOR 07/20/98 10:29 15.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer U9 (T, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING ype or print)t)NORTH ANDOVER,MASSCHUSETTS ���� Dateuilding Locations !Ud //L/GY�� G• Permit # 3 76 Amount Owner's Name ,�" �C" LZ�e New Renovation El Replacement 0 Plans Submitted n FIXTURES H a � a a SLRBM I��v>avr f ISE FUM 2J`D FID(R MFLOR 4M RfM 5M FLOM 6M FUM 7M H D(R SIH FLOCK r (Print or type) Check one: Certificate +� Installing Company Name % Corp. Address �/76�A s' ' Partner. Business Telephone Finn/Co. Name of Licensed Plumber: �'�� '_ �7r� —S� Insurance Coveraae: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I,the undersigned,have been mdde 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 Mass to Plu i g C d Ch ter]42 . f the General Laws. By: 5ignature or Licenseaum Type of Plumbing License Title City/Town License Num Der Master ❑ Journeyman APPROVED(OFFICE USE ONLY MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFI (Print or Type) ] NORTH ANDOVER Mass. Date Build" g Location - / Permit # � � -Owners Name / New Renovation Replacement II Plans Submitted n c u� of m Q Q c0 W CT m w ~ U _ U4UA C yet �_ _ to to 07 d — - C7 2 E. W cLLA am,. Lail c� y a oQ. o Itt 1( tI I. .•I.- :�t - ( --�._- �--� --• - BASE&lEaT f I I I tt! I ( I ! ! t t ., t -IST FLOOR ZXa FLOOR j 3RQ FLOOR I � ! ! -! I ( I t� � I I I ( I fI ( j __I.. , � ...`t Ii I- - t-�– tt-- STI_ H FLOOR . . ! A -A, {I ! f i I It I { I { I 144 j! tt( I .J..__.� .- .i__.1-��:.�.�Z,.1_... �.._ STH FLOOR 77K FLOOR STH FLOOR (Print or Type) Checkone: Certificate Instailing Company Name ,/r, J7` a Corp. Address - Partner. - ��71 �n .✓CL—.�— f �, � Cf Firm/Co. Business TelephoneC>1q jO Name or Licensed Plumber or Gas Fitter Insurance Coverage: Indicate ,re ;•/Ce o: insurance coverage_ by c.- eckin_g the aooroariate box: -- Liability Insurance policy, Ot^er tvice o; indemr,it Bond -: Insurance Waiver: I, the urdersicnet, have been made aware that -the licensee.of this appiication does not have ar,v one or the above three insurance _cover ages ,_._ Signature or owner/agent or procerty Owner Agent I hereby cc:tify that all of the det&ik and information I have LU!:rnitte3 (or entered)in&bore application are true u+d acc=zte to the best of my k-tOwledge and tttat aU piU Mbin; robe and tniututioat undo !°-writ isrccd Co: this &ppdetiaa will be in`ea piiutoa VWX all pettlaatt ptarisiona OC t.5e Sta&sachuactta State Cas Csde zr4 QA;Ptes Ica.u=a C.cie i I.Aws. " By TYPE-' LICZNS Tile { Gasiitter Signature of License- Master P1er o Gasfitter Journeyman az , APPROVED (OFFICE USE ONLY] License isumoer Date. . .. . . . .. . . .. .. Q. NpaTH TOWN OF NORTH ANDOVER 8 PERMIT FOR GAS INSTALLATION s 6 1SSACHUgEt 7 N .r r- `1 � This certifies that . . . . . . . . . . .. . :". . . . . . . . . . . . . . . . . . . . . . . . . . i M has permission for gas installation . . . . . . . . . . .o in the buildings of . . . . . . . . . . . . r ' : . . . . . . . . . . . . . . . . . . . . . . . . at . F..'. . .6. :. . . . . . . . . . . . . . . . North Andover, Mass. Fee. . . :. . . . . Lic. No.. :. . . . . . . . . . . . V' ��. . . . . . AS INSPECTOR' WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File Date.. �Av U. r�....... . t NORTH •y1 Of a� TOWN OF NORTH ANDOVER s i PERMIT FOR GAS INSTALLATION Ioh SAC•HUSE�4 a a ��This certifies that .�. . . . . .� . //`` . . . has permission for gasInstallation in the buildings of -� 1�� . `. i 1 - . . . . . . . . . . . . . . atA, , !' . . . , North Andover, Mass. Fee.��.� Lic. No.l. l . . . GAS INSPECTOR heck# 4719 MASSACHUSETTSUNIFORM APPUCATION FOFr PEPMff TO DO GASFITTING (Print or Type). Date 2Permit gulding;Location• 60 )E ale WA-4 L Owner's Name 4 Iti` ?LC7 Type of Occupancy New p Renovation-0 Repla GP--- Plans Submhta& Yelp No p i a a W.. a.. Y� Z, a as N. N C Q �:, a► _ F oe: Z, - z o. Z O W < Cy W, O C it H N C N a V W N Z_ i. N' all id zp ? W < C 10 X 61 O30 0 Z O S SUB—BSMT. BASEMENT 1 ST FLOOR 2N0 FLOOR 3RO FLOOR _ 4TH FLOOR STH FLOOR 6TH FLOOR TTN FLOOR aTHFLOOR . Installing Company Noma Check one:. fie; Address - 544 tion- - &4 yu rexq . n;i i<i p Partnership Business Telephone - £r9 - �A Firm/Co. Name of Lkensed Plumber or Gas Fitter. St•eL�-eo I A(Ac6.,2ta �TQ , INSURANCE COVERAGE- I have a curreAllabilty,kwurancepoLpy or Its substantW: equivalerd-whkh-meets the requiremerft of.zMGL-,Q1..142., IYes )q No 13 if you have chedwd-ys&:pte=4ndiaW—ka4yne�overage-by checking the appropriate,box. A IWAIty insuranoe=policy Otho typeof..in lemnity.Q gond p OWNER'S INSURANCE WAVER:i am-aware that the Jk %ft does Tnot:have- the insurance.coverage required.by. Chapter 142 of the.MasL General Laws. and 4hat.my signature on this-permit application waives this requirement. Check one: OwnerO Agent.p Signature ot.Owner.flr:O�wrtiers Agent.. I hereby cerW that all of the details and intormation 1 have submitted(or entered)in above application me true and accurate to.the best of my knowledge and that all plumbing worts and Mstallatiorts-WwmW under the pernut is wW for this application will be in compliance with all pertinent provisions of the MLwachusetts State Gas Code and Chapter 142 of the General Laws. 9y Tj of License: Plumber ggnatM of GM&a Plumber ori Title Gasfitter City/Town et Ucense Number 31000, rneyman BELOW FOR OFFICE USE ONLY FINAL, INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO OASFITTING NAME A TYPE OF BUILDING, LOCATION OF OUILDINQ PLUMBER Olt 0A8F1tTER PEMiMIT GIMMMIfiED DATE ... 20 ,� OAS INSPECTOR t' Date.�/! 4,, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMusE� This certifies that. has permission to perform . .r1l,..: ! / (, C y.. . plu bi ari the buildings of . �/ at�Q��if. .,�. (/ . . . . . . .. North Andover, Mass. Fee r. . . . .Lu. No/-- ./ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . r. PLUMBING INSPECTOR Check # 5 ; : 0 1 •� 0 - � N C R Z � rs R8 g �82c WATER CLOSETS KITCHEN SINKS C LAVATORIES - Z HATHTUB 1 0 c� SHOWER STALLS I DISHWASHERS ❑ $ g ` DISPOSERS9. _ _ LAUNDRY TRAYS 31 ; 'O S, C WASH. MACH. CONN. lo p r 3' HOT WATER TANKS s g TANKLE88 � V SLOP SINKS Z (0 FLOOR DRAINS ❑ CCAS TRAPS Q [:I ❑ ❑ URINALS N lu DRINKING FOUNTAIN Z I AREA DRAIN D WATER PIPING M1 . ROOF DRAINS n � $ Q cl Cl '�° BACKFLOW PREV. OTHER FIXTURES: O � } o i� BOILER MATE '$ GREASE TRAP c C SCULLERY SINK O '1SH OWER VALVE Z \+ ' Z jg o O o 1 �1 �da ele� ' BELOW FOR OFFICE USE ONLY 7 l FINAL INSPECTIONS SKETCHES FEE PROGRESS INSPECTIONS v N0. APPLICATION FOR PERMIT TO 00 PLUMBING y 1 UNDERGROUND ROUGH ;f i COMPLETE ROUGH FINAL INSPECTION f I PERMIT GRANTED DATE PLUMBING INSPECTOR 1 I Office Use Only �-7 t GIBE LIIIIIIIIIIIIIIIPII I of 505ar4usEt5 Permit No. �elJarimE>ti of lluhlir —9-�fetq Occupancy& Fee Checked 3/go (leave blank) BOARD OF FIRE PREVENTION REGULATIONS 527 VJR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts EIectrical Code, 527 CMR 2:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date d a)Q or Town of NORTH ANDOVER To the I pecto of Wires: The udersigned applies for apermit to perform he work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction ith a b ding r erm Yes No r (Check Apprep t Purccse of Building v r t Utility Authorization No. Existing Service Amos —_/ kits Overhead _ Undgrndr, /No. of Meters New Service Amps.46w I�`v VCits Overheae _ Unagmo Y No• of Meters Numcer of Feeders and Amcacay r Location arc Nature of Prcoosee Eiecmcal 1.11crx Totai No. at L;gr,ung Gutters i No. o .:o . Hct ' s i No. of Transformers KVA No. of Lignting Fixtures i Swimming Peoi gnoe_ in- _ ! Generators KVA i I No. of Emergency Lighting No. of Recectacie Outlets No. of Oil Burners ; Sarery Units No. of Sw tcn Outlets No. or Gas Surners I FIRE .ALARMS No. of Zones Total No. at Detection ane Nc. cf Ranges I No. of Air Cerc. tans Initiating Davices _ Heat Tatat Tatai No. at 0iscosais No.ct Pu _ „- s Tons K'.V No. at Sounding Devices _ r No. of Sert Contained No. of Disnwasners - ScaceiArea Heating Oetec-mri/Sounding Devices L — Muntcfoat Other No. of Orrers Hearne Oev:ces KW coat Connect:dn No. at No. of Law Vortage No. of '.Vater Heaters KY`! 1 Signs Sailasts Winn; No. Hydra !Massage Tubs No. of `.Motors Total HP OTHER: / INSURANCE COVERAGE. Pursuant to the recutremems of '.lass- .•uset:s ;enerat Laws c — I have a current Liaotiity I urance Policy inciucmg Ca set Gee rattans Coverace or is suns:anual eeuivatent. Ya _vvuuUU nave suomtttea vada pr f et same to the Office. YES NO _ It you nave cnecxea YES. ptease natcate the tvice of coverage cy checxtng the a0pro ate aOx- INSURANCE SONO = OTHER = (Pease Scec:fy) (Exotratton Oate) Esumatea Value aZectnc 'Nork 5 Fnat Wcrx :o Stan Inscecuon Oate Racuestec: Rough � t Signed unser the Pe es of p ury LIC. NO. FIRM NAME U . N Licensee Signal— s. Tet. No. Alt. Tel. "la. e Address OWNERS INSURANCE WAIVER: I am aware !hat the !:c a aces not have the insurance coverage or its suostanttal eautvalenA� ente- autres ny Massachusetts General Laws. and that my signature on th:s cermt a0pncatton waives this redutrement. O/wrjfr g (Pease cnecx one) <� C t' 00 'e+eenone Na. PERMIT FEE S _' (Signature at Owner or Agents /( ( ` "` /A Date..../.. ... .... .....!.......... gOR71� °f'"`°:•�"�0 TOWN OF NORTH ANDOVER w PERMIT FOR WIRING ,SSACMUS� � r This certifies that ...........Nsx4.l....f.�S....,...... (.....�............................ has permission to perform ��`�.. U 'P wiring in the building of.....1 0-0........... ....................................... 'q M at...^. ....... �.: .1'Q...L t�.y......El:....... .North Andover,Mass.c ............................................................ ELECTRICAL INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer Ottics Use Onty 014r LIIIIITITIIIIIUEII I Df 5n5z1L 1tt5 Permit No. V Occupancy&Fee Checked y � �e�rarimxzti of�uhltr iq p 3190 (leave blank) BOARD OF FIRE PREIlENTiON REGULATIONS 527 C'dA 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Cade, 527 C R 12: (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (XX or Town of NORTH ANDOVER To the I spe or of wires: The udersigned applies for a permit to perform th lectr cat work described below. Location (Street & Number) 0 t Owner or Tenant Owner's Address , 77 Is this permit in conjunctior n wit a buil 'ng permi : Yes No I (Check Appropriate Box) 'cc Puracse of Building V�.� Utility Authorization No. Existing Service Amos Vc is Overhead _ Unagrnd No. of Mecers New Semite 1Io�Amps Volts Overheae _ Uncgrna E� No. of Meters Numcer of Feeders anc Amcacity Lccacicri arc Nature of Precosed Electrical :'Vcrx Tocai No. of L gnang Outlets i No. ct :-ct --­-s i No. cf 7ranstcrmers KVA I Above In- — No. at Lighvng Fixtures i Swimming Foo' grna _ cmc. ! Generators KVA I I No. of Emergency Lighting No. of gecectacie Cutlets No. of Oil Surners ; Battery Units No. at Swrtcn Outlets No. or Gas =urners I FIRE ALARMS No. of Zones Total No. at Cetec:ion ane No. of Ranges I No. of Air Cor.c. tons Initiating Oav:ces !-eat Total local No. of Oiscosais No.cf v Pu^_s Tons KIW No. of Souncing Oevices _ No. of self Containea No. of Oisnwasners - ScacetArea Heating KVJ Oa:ec.:onlsouncing oev:ces KW Local — Mun:cicai Other No. of Or/ors I Heauna Oewces Connec::on No. at No. of Low Voltage No. of .Vater Heaters KV/ I Signs Ballasts Wiring No Hvaro Massage quos No of Motors otai H° OTHER: INSURANCE COVERAGE: Pursuant :o the reaturements of %lassacr- ets ;C�, , ws c - NO = I have a current Liaoliity Insurance Policy Inc:uc:ng C� _-:ere cerat:ens or its suostanaal ecuivaient. Y S have suam:ttea valid grit t-ct same to the Gttice. YE3 NO = It youcxea !ES. please na tate :he type of coverage cy checx:ng :he ao roo to pox. INSURANCE BOND = OTHER = (Please Scec:tyl (Exe:ration 0atei Esttmatea Value of c;nc-I 'Nark S Worx :o Start 414 Inscec::on nate Pacuestec: Rougn F nal S;gnea unser : P Me of p ury. 0 7y F;RM NAME 1C. NO. LS;gnar•re icensee 3u 9I. No. /17 2 Alt. Tet. No. ACdress OWNER'S INSURANCE WAIVER: I am aware :hat the L:c s e ones not nave aor nation a coverage or its suentanttal eau:valenAt ente' ou:rea by Massachusetts General Laws. ane mat my signature on :^s term:[ aoPucac:on Naives the reawrement. OwAr �� (Please cnecx ones -etecnone No. PERMIT FEE S (Signature of Cwner or Agent( Date... Goo 'aORTIf O�tt.ao .a,ti TOWN OF NORTH ANDOVER A PERMIT FOR WIRING a �► •O��r�o����'h M �SSACMUS� �y This certifies that ........ v ...'?.c 5.............'�..�. F�.....t.!.�:................. has permission to perform ....1\\) t 1........ ....... 1..�:.f..d.:.l. ..ti wiring in the building of.....T v (� U� .0<7' .. ...f............................... .� ..rh ti at.... . .. .........��.�... ....�.k.�q.c`. ....��........... ,North Andover,Masi; ,j �.✓:vJ.. Lic.No. .�s�?7/........................................................... ELECTRICAL INSPECTOR Q�d.1Ug7 12:11 WHITE:Applicant CANARY: Buy ing ept. PINK:Treasurer r � , The Commonwealth of Massachusetts " `'" 00y n` r..rett Sn. V ' Deportmcnf of Public Sofcty Occul.ancv S fee Checked BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1200 1/90 heave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance With the Massachusetts Electrical Code, S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL IiTFORHATION) Date /— /S— 5'7 City or Town of 71 04 VOpA,,EAp To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) /'y/ '01elee Owner or Tenant Owner's Address .SAmE 508) 975—98/� Is this permit in conjunction with a building permit: Yes ❑ No © (Check Appropriate Box) Purpose of Building Utility Authorization 110. Existing Service Amps % Volts Overhead El Undgrd��� No. of Meters _ New Service Amps / Volts Overhead ❑ Undgrd❑ Ito. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work Installation of Alarm System No. of Lighting Outlets No. of Hot Tubs ' No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners , No. of BatteryEmergency Lighting UniNo. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges Total No. of Detection and 8 No. of Air Cond. tons Initiating Devices eat No. of Disposals No. of Puummps Total Total 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 Connection No. of Water Heaters SignsBallastsBallasts ( Wiringlt ,&4 em 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 ❑ BOND ❑ OTHER❑ (Please Specify) 0o Estimated Value of Electrical Work S /'/0 (Expirationate Work to Start /—31-9,Z- Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAME A.D.T. SFCURITV -SYSTEMS NORTHEAST INC. LLC. NO. 1231C Licensee DONALD A BROOKS Signate NO. 1231C Address 60 William Street, Wellesley, 8 s. el. No. 413-732-4400 Alt. Tel. No. 617-431-5831 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts GeneralwsZa,and that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent 7C f NOR7N 1 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ,SSAcmus� �.:.. 1. ...............`.....}�......::. ..r............' This certifies that .. .. .......:..... .. .... ........ has permission to perform ............ ............. r�..�.``. .tv"� . . ................... r �/� wiring in the building of �`E'.l.!r��f......./.U�. `'� ' F ci at. �.......................f ?................ .North Andover,Mass. f ! Q/ Fee. .: ..:.. v. Lic.No. ............................................................... ELECTRICAL INSPECTOR WRITE:Applicant CANARY:Building Dept. PINK:Treasurer Date..... //.t 807 TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSACHUS This certifies that .... 1ec It? ., .......................................... has permission to perform ...... "! , (Al, l.....1./.v!............................... ...I...... wiring in the building of.....I.-O-a...... ........................................ at..6 .....`.......?. . .t' ......A( ................. .North Andover,Mass. Fel �3...... Lic.No 4.1,4ff.............................................................. ELECTRICAL INSPECTOR ti WHITE:Applicant CANARY: Building Dept. PINK:Treasurer c office Use Only GI hf Crommunmellith of fauo�>. Permit No. Q 7 Jtx[T rnt of 11abiit —Aufttq Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 C JR 12:00 W90 peave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacnusetts Electrical Code, 527 CM �*12:0(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date(X)j or Town of NORTH ANDOVER To the I speces: -The udersigned applies for a permit to perform t e e ectricai work described below. Location (Street & Number) - Owner or Tenant I Owner's Address /v Is this permit in conjunction wi h a b ding per it: Yes _ No C (Check Appropriate Box) Puroose of Building r /�� ` Utility Authorization No. 2dQ YY Existing Service V Amos _ I Bits Overhead Undgrnd r^1No. of Meters New Service 040 Amps �Og/� Volts Overhead Undgrnc r&--' No. of Meters �! Numoer of Feeders ana Ampacity Location and Nature of Prcoosed Electrical Work Tota' No. of Lighting Outlets I No. of Hot '.bs No. of Transformers KVA No. of Lighting F;xtures i Swimming Paci Baa e= grrc _ I Generators KVA i I No. of Emergency Lighting No. of Recectac:e Cutlets No. of Oil curners Battery Units No. of Switch Outlets I No. of Gas Surr.ers FIRE ALARMS No. of Zones 'otai No. of Detection and No. of Air Circ. No. of Ranges I tens Initiating Devices Heat To:at Total No. of Disposals Nd.of Heat techs -oto No. of Sounding Devices i No. of Sett Contained No. of Dishwasners Seace/Area Heatina K.V Detect;on/Sounaing Devices Muntcicat No. of Dryers I Heating Devices KN Local _ Connec•;on _7-7 Other No. of Vo. -,r Low Vcttage No. of Water Heaters KW I Signs Bailasts Wiring No. Hyaro Massage Tubs I No. of Motors Totat HP OTHER: INSURANCE CCVEF2AGE. Pursuant :a the requirements��NC�Z -f Massac.m;sers general Laws _ I nave a current Liapiiity Insurance Policy inducing CJeratiens Coverage or its suns:antial equivalent. YES O _ have suomtttea valid proof at same to the Office. YES If you have checxed YES. please indicate the type of coverage Cy cnecKing the ac�pro [e oox. INSURANCE !7! BONO = OTHER = (Please S_ec:`-�) (Expiration Datet Esurnatea Value of .e •roc 'Mork 5 Fina' Worx to Start Inspection Data neat:eS:eG: Rough Signeo unser t"/Pen ties of p ury: LIC. NO. FiRM NAME Licensee Si na: re LIC. No. le" H Bus. .el. No. C ,vim Alt. Tel. No. Address OWNER'S INSURANCE'NAIVER: I am aware that t .censee apes not nave the insurance coverage or its suostannat ecuiva'ent as re- auirea by Massachusetts General Laws. and :hat my signature on *.n:s _-ermit application waives this reouirement. Owner Agent (P!ease checx ones `dv Tetecrone No. PERMIT FE (Signature of Owner or Agent)