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Miscellaneous - 73 WATER STREET 4/30/2018
�w I Zoning Bylaw Review Form 9 Town Of North Andover Building Department *`9se Vit" 27 Charles St. North Andover, MA. 01845 a Phone 978-688=9545 Fax 978-6884542 Street: f10 ryv 1z &f e- , f - Ma /Lot: y 3 Applicant: �,u a. faP C s c i Request: C'A •9,v 6, p er, e- 121- . rYJ.4 re ""o S.9 /a a r`o : J=Q E' S fa fjlls rti •ems Date: c1111710 -c( Please be advised that after review of your Application and Plans that your Application is DENIED for the following Zoning Bylaw reasons: Zoning Remedy for the above is checked below Item # Special Permits Planning Board Item # Item Notes Setback Variance Item Notes A Lot Area Common Driveway Special Permit F Frontage Variance for Sign 1 Lot area Insufficient Independent Elderly Housing Special Permit 1 Frontage Insufficient Earth Removal Special Permit ZBA 2 Lot Area Preexisting S 2 Frontage Complies Special permit for preexisting nonconforming 3 1 Lot Area Complies 3 Preexisting frontage y�e S - 4 Insufficient Information 4 Insufficient Information B Use 5 No access over Frontage 1 Allowed G Contiguous Building Area 2 Not Allowed 1 Insufficient Area 3 Use Preexisting 2 Complies 4 Special Permit Required e S 3 Preexisting CBA y� S 5 Insufficient Information 4 Insufficient Information C Setback H Building Height 1 All setbacks comply 1 Height Exceeds Maximum 2 Front Insufficient 2 Complies 3 Left Side Insufficient .3 Preexisting Height S 4 Right Side Insufficient 4 Insufficient Information 5 Rear Insufficient 1 Building Coverage 6 Preexisting setbacks S 1 Coverage exceeds maximum 7 Insufficient Information 2 Coverage Complies D Watershed 3 Coverage Preexisting S 1 I Not in Watershed e- s 4 Insufficient Information 2 In Watershed j Sign 3 Lot prior to 10/24/94 1 Sign not allowed 4 Zone to be Determined 2 Sign Complies 5 Insufficient Information 3 Insufficient Information E Historic District K Parking 1 In District review required 1 More Parking Required 2 Not in district e - -S2 Parking Complies 3 Insufficient Information 3- Insufficient Information S 4 1 Pte -existing Parkin Remedy for the above is checked below Item # Special Permits Planning Board Item # Variance ,6-11 Site Plan Review Special Permit Setback Variance Access other than Frontage Special Permit Ae-3 Parking Variance Frontage Exception Lot Special Permit Lot Area Variance Common Driveway Special Permit Height Variance Congregate Housing Special Permit Variance for Sign Continuing Care Retirement Special Permit Special Permits Zoning Board Independent Elderly Housing Special Permit Special Permit Non -Conforming Use ZBA Large Estate Condo Special Permit Earth Removal Special Permit ZBA Planned Development District Special Permit Special Permit Use not Listed but Similar Planned Residential Special Permit Special Permit for Sign R-6 Density Special Permit Special permit for preexisting nonconforming Watershed Special Permit The above review and attached explanation of such is based on the plans and Information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such Verbal explanations by the applicant serve to provide definitive answers to the above reasons for Any inaccuracies, misleading Information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled `Plan Review Narrative" shall be attached hereto and incorporated herein by reference. The building department will retain all plans and documentation for the above file. You must file a new permit application form and begin the permitting process. i Building Department Official Signatl�r# Application eeeived ApplicfitionDenied Plan Review Narrative Ther ollowing narrative is provided to further explain the reasons for DENIAL for the 'CICA for the property indicated on the reverse side: Pb h Y 2t F ?q `t• F it 4 i N� `4 i� x"r!'4A4!`ti4"a "M T,yi 17 lFl ,� C =" b t { ii.5.��2< "•'vs' y1 4 '7W �'frl, ttY E,{6 "f�ii'fi�t le 001A N R e L)' p i U � n! P c / � j /�� rttsr. .. -S, Ile Police Zoning Board r Department of Public Works k e. cs o0 Historical Commission Other Building Department or P v /✓'G v? -fir• f�r�LT S .ACS �rr �-hW. /�Cr�sl�'" _. 5P4 JC,r �-A C_. ,�-e,aC/ -/Z-� Referred To: Fire Health Police Zoning Board Conservation Department of Public Works 10 Planning Historical Commission Other Building Department NO c e-. To: Planning Department 27 Charles Street North Andover, MA 01845 From: Ronald Cuscia 69 South Bradford Street North Andover, MA 01845 Re: Change of use approval Date: August 30, 2004 Dear Sir: E K n+np fv�i:�F FLANNIN GL-PAfl I MENT AUG 2 4 20C I am interested in purchasing commercial property located at 73 Water Street.. The property previously housed a makeup salon on the ground level. I would like to request a change of use approval to establish a family operated food establishment in that ground level space. My intention is to utilize the lower level space of approximately 475 square feet primarily -as a take out restaurant and the upstairs apartment as a family residence. I intend to employ no more than three employees and to operate between the hours of 11:00 AM and 9:00 PM Sunday -Saturday. In addition to curbside parking, there are six parking spaces available on the premises. I respectfully await your response. Sincerely, /; Ronald Cuscia L_ tl�z MCAS 9272 sARRV J MARTIN W-iUU4/VUa ,; 33.se - GC//'9 PLOT r ArrleaaT ca> lvr 20 INN :rule Mum "a .PLAN ro nm owwr rar rm owxu my rs maim Ox W ria zor As saawr An nur it oars cajou" ►tri some, JWWUI ours jwaia=c ssrm= RUN smarm t zor t mm! I lrulerft" rsle>a" Mr rl S D/JC ZWO M NOr DRA IN FOR l acim of rout r ao MAXM A Alen As oeom oN 2Soo 9.01"-qG / .r l-49/4FR y sraPxrly tour /to 17c�G / 99B rX& PIAN Pole Y sas — Nor MR BouKA�tBr arlsxx uoN. Ba(NBOT INFaRYArroM 1[�RRtYdCX JPNCIJVYRRIKC SERVICES A(A TAXER FROM ertaraa iercmeos. MQ srRaar n, ANDOYNX YA88ACHU8BY'r9' 01810 . Date.... .3 A. .?".. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatC/4� T � ` C' ........................................................................................... has permission to perform......S !tet O t'. 'D •P ` r- C �e S ....................................................................... wiring in the building of ......�...`.4..'� . S `� �� .' ......................:......................................... 3.... /Z � ............... . North Andover, Mass. Fee .... �? .,?........ Lic. No�9......... • /1ic,+�� ccs �il �-*--- ELECCRtCALINSPECfOR J Check # ! 5437 Commonwealth of Massacht►setts Department of Fire Services BOARD OF FiRE PREVENTION REGUL� IONS APPLICATION FOR PERMIT TO All work to be pertixmeil in accorclall e with lite M� (PL E.4SE. PRINT IN INK OR TYPE ALL INFO , 19 TI City or Town of: i� 4�b0 e d By this application the undCrsigned gives notice of his or I el -ii Location (Street & Number) k_ � Owncr or Tenant LAelvis Owner's Address Is this permit in conjunction with a building permit? Purpose of Building . Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of* Proposed Electrical Work: lJ(,/ST. JJ S-,%D�� ��%e / ci r -- _N Official Use Only [Pcrniit No.upancy and Fee Checked.11/991 (leave blank) PERFORM ELECTRICAL WORK ssachosctts Elccth'icall Code (MEC), 527 CMIZ 12.11(1 I _ To the Inspector mi/!C�S: untloll t.O-L)CI'fOl'I11 the Clcctric,al work described below. Telephone No. 1'es ❑ No II (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Aleters No. of Meters :burnuuurnunuJ nctur/ r/ ursvrea, or ax requiredhi the /nspet-wr u/ INSURANCE COVERAGE: Unless waived by the owner, no permit fol- the performance of electrical work may issue unlCss the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. "I'hc undersigned certifies that such coverage is in force, and has exhibited proof of sante to the hermit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Wort: to Start: 3 (J Inspections to be rcqucstcd in accordance with MEC RUIC 10, and Up011 C0111plC11011. I c•ertifjJ, antler diepaills and penalties of'peijarp, that the inf n -matron oil this ggVication Is trite and cowj)lete. FIRM NAA4E: rAe T'#F�yl�C j'f f C� LIC. NO.: Licensee:, 714 ( �";s��2 i`/�} Signatu • = L1C. NO.:.3pllo�L jl/ a/Jplicnl n/eI �.telnp in the lic ensc• nuCniker line.) Bus. Tel. No.:66-? �%J'Y. A 2 ? Address: (jX l�/' J� e- -7 /?//-� D s'Q �/ Alt. Tel. No.:66??G s 3 7, ONNINER S INSURANCE- WAIVER: I am aware that the Licensee does not have the liability insurance coverage nurIllally required by law. By Illy signature below, I hereby waive this requirement. I and the (check one) ❑ owner ❑ owner's Boum. Owner/Agent Signature Telephone No. PERMIT FEE: $ -....• ••�.. •,...,r .... l..nvrvn� v.....c ruul' (re nvrn'eel Ill' 117" /11S )ector U/ II II,cs. 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 No. of Lighting Fixtures Swinunin 6 g Pool Above ❑ In- ❑ o. of Enjergency ig I Ing rrnd. rntd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Cas Burners No. oi' Detection and Initiating Devices No. of Ranges No. of Air Cond. To sl No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Selt=Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection EJ Other No. 01' Dryers Heating Appliances KW Security Systems: Na irf Water No. of No. of No. of Devices or Ec uivalent Heaters KW Sirens Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Ec uivalent OTHER: :burnuuurnunuJ nctur/ r/ ursvrea, or ax requiredhi the /nspet-wr u/ INSURANCE COVERAGE: Unless waived by the owner, no permit fol- the performance of electrical work may issue unlCss the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. "I'hc undersigned certifies that such coverage is in force, and has exhibited proof of sante to the hermit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Wort: to Start: 3 (J Inspections to be rcqucstcd in accordance with MEC RUIC 10, and Up011 C0111plC11011. I c•ertifjJ, antler diepaills and penalties of'peijarp, that the inf n -matron oil this ggVication Is trite and cowj)lete. FIRM NAA4E: rAe T'#F�yl�C j'f f C� LIC. NO.: Licensee:, 714 ( �";s��2 i`/�} Signatu • = L1C. NO.:.3pllo�L jl/ a/Jplicnl n/eI �.telnp in the lic ensc• nuCniker line.) Bus. Tel. No.:66-? �%J'Y. A 2 ? Address: (jX l�/' J� e- -7 /?//-� D s'Q �/ Alt. Tel. No.:66??G s 3 7, ONNINER S INSURANCE- WAIVER: I am aware that the Licensee does not have the liability insurance coverage nurIllally required by law. By Illy signature below, I hereby waive this requirement. I and the (check one) ❑ owner ❑ owner's Boum. Owner/Agent Signature Telephone No. PERMIT FEE: $ 0'' °c 4 A NORTH ANDOVER BUILDING DEPARTMENT �� °wwr.o �Rt4y 400 Osgood Street SSACNUS� Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE: NAME: 1 , - dU CLLZv vCA - O ADDRESS: 03 U6 qr ;a) -�- ZONING DISTRICT: TYPE OF BUSINESS: BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: ; YE NO ter_ BUILDING INSPECTOR SIGNATURE Revived 11.5.04 BUSINESS FORM FOR TOWN CLERK To: Planning Department 27 Charles Street North Andover, MA 01845 From: Ronald Cuscia 69 South Bradford Street North Andover, MA 01845 Re: Change of use approval Date: August 30, 2004 Dear Sir: I am interested in purchasing commercial property located at 73 Water Street/The property previously housed a makeup salon on the ground level: I -would like to request a change of use approval to establish a family operated food establishment in that ground level space. My intention is to utilize the lower level space of approximately 475 square feet primarily as a take out restaurant and the upstairs apartment as a family residence. I intend to employ no more than three employees and to operate between the hours of 11:00 AM and 9:00 PM Sunday -Saturday. In addition to curbside parking, there are six parking spaces available on the premises. I respectfully await your response. Sincerely, Ronal` d(a'Z( (G_ RECEIVED AUG 3 12004 R�R Q � Q V h z 00 w� cnQ oar Oa z. Qa O w. Q O � OOw n v O - 1 O W W FUF QZ�. v� oo W Q o Ca � a > c C,Q O $ az Location 173 6VA -� —r �Z No. 13 Date Check # S 1 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ e a Foundation Permit Fee Other Permit Fee TOTAL $ 16218 /4 �C� �=- Building Inspector IFA TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING NF :$C Ql>il&J�C i�I t BUILDING PERMIT NUMBER: 4113 DATE ISSUED: 3CP C7 SIGNATURE: Building Commissioner/I for of Buildin Date SECTION i- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: e;L51 Map Number P3`rcelNumber 1.3 Zoning Information: 1.4 Property Dimensions: ,2 3 ?, Y l Zoning District Proposed Use Lot Areas Fromm e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R 'red Provided R 'red 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 0 Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print)% /AA Address for Service: Sig nattlr6 Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: Not Applicable ❑ C S i icensedlConstruction Supervisor License Number Ad es: r E tra ron Date Signa Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone OU M z O O z M 90 O D r M r r z^ Q SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit qwt be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build rmit. Signed affidavit Attached Yes ....... IV No ....... ❑ SECTION 5 Description of Proposed Work check licable New Construction ❑ Existing Building Repair(s) Alterations(s) Addition 19 Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: sc ®'�.C�,,•�....v3-'a/-L,_. �—�. 1'V"�- cE' ,' (.�.���L' t�' �— � t "c� . 4 2 (E. �. �►.... SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building(a) o Building Permit Fee Multiplier 2 Electrical o. s (b) Estimated Total Cost of Construction 3 Plumbing • 13—t F c� " Building Permit fee (a) X (b) J 4 Mechanical HVAC ' cr--o -o�'�-- 5 Fire Protection 6 Total 1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH DING PERMIT I, d- C,/ H reb authorize L. (,� beh f, in in ers rela o authoriz y t ildfng Si nature of Owner as�O7w-ner/Authorized Agent of subject property Lv tj V c— to act on permit application. h7 41 � Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, L) �'1 t ��t[� �� 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 I G. rl ::S e Print Name /�� // Si ature of OkvherrA ent Date / NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlABERS 1 ST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIIWNSIONS 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 2 ¢-- S,, 4-e--- %3 LJ 10/21/02 MON 10:21 FAX 978 882 9272 BARRY J MARTIN - MVAS 10004/005 I f.0//'9 7-25"10:p-1 a PLOT PLAN i WROY C=Tnry fro = rnU WUJIOR Alun ro rm 84" n ar w owzu NG is Locim ox riv rrra Lar as sapIN AND fWT Jr DoaB clomra" NTH TH97- .-• SommG Raouumuv imna DWo .92men mu SMA" "B & LOT Uwe �D_ " i impan crmw rear rlos imu"o JS for � DRAVN FOR zocilwa W rm r W sAZUW Apra es 000 WN ON A o2s�9g�9G o► f y t tZAD-'�r Bi'BPfWK JUTS Np s .. X rJUS PLAN Sm Nor FAR ' r ll$R:mom. aoftwINmPYom YRRMdSXCiVRRR1G SRYICBS vir9oD1A r/RN !'QM AJ$f1G R•C4D. SwEr "DOMP, MASSACXUSSM 0100 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: C—' etx 3_ L,--�- Applicant .-7//(j R Date NOTE: Demolition permit from the Town. of North Andover must be obtained for this project through the Office of the Building Inspector The Commonwealth of Massachusetts _ Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name \ / / Please Print Name: �) c,. ,� [_ �it_rt. l.. c� /.S C Location: Lz• t 9 .2.2— V I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for mv'employees working on this ppb. Company name: City- " Phone #: Insurance. Co. Policv # Company name: Address City: Phone #: Insurance Co. Policv # Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1.500.00 and/or one years' impriso . t_as as_c l penaltiesm2heSam.�of��T9P WDRIC ORDERand_a fine.�f�$100-0D��riay.against.v� 1 understand that -a copy of statement may be forwarded to the Office of Inwesti ons of the DIA for coverage verification. I do hereby ih' un the i and pe (ties of perjury the inf tion ided above is true and correct SignatureDate % 0 3 Print name J �dEK, s ld zS �`i - Ph- 7Z.?� ZCI 1. Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing. Building Dept E]Check if immediate response is required E] Licensing Board E] Selectman's Office Contact person: Phone #. F, Health Department El Other Dii i Licerss� C�S�UCTION SU'. { Number.-' ; # �" Expires 0M$04 it firs: 77 f f 4GL(S , "f Ad A try € a(;r, O z OOC O LE v cn U .05b p u. O aG U C [z, ® a p a: G u: CY ® w w p w cn C w x o 0 w' C,3 w z w v cn z �i cn cn o m c :;c c o � C N ' � O vV �:•C_ O L m O O C N O 41 rO+ ® ti a E NMA CL co m � N C 'C Co ' N 4 O 44is . -E E ro ca.v � m cm if r •dC t O m OCc N O .O Cc -,, .5; ® cm C Q tick ` CL =CD = m m� =3: N F' C:,ymo12 m t LU �. CO2 Oe �_ W C Z � •Ofoal N O cm C3 ® p m C COD CL m ® O 2 . o ` (A O_ qr CL".. M 1-10 T a CD C2 C v Z CD CL co y ® C cm CD Q C L W W •CD o CID -Ir � ® O ® a C Q cm ccC CD c0 CL C..2 CA � C C. CA 0 U) U) w w crw U) Date. i -/4 ..n- . f gORf", TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING •D••i�D �A,`1' ' P ,SSAC14USi ----} . This certifies that :- . ....................:.. . has permission to perform . ✓�? ^ �: �'.. -.../.� , . rj �'e- plumbing in the buildings of .. . . at . �- ... �-�.'� '.. /4......: -.. �. , North Andover, Mass. Fee.': ...... Lic. No.......... /. i, i,r;1c-,y.�l.t............ . LUMING INSPECTOR Check # ` 5494 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location tlr rs 7 Owners Name Tzpe of Occupancy New Renovation Replacement Date 7 -'Sr Caj'-e-rr Permit' Amount—LE Plans Submitted YesNo . 1:1 (Print.or type)Corp. Check one: Certificate f< installing Company Name ��J'0') Ad8ress '\�C' k -r r '�s j Partner. ee, Bidi" ness Telephone Name of Licensed.Plumber: Insurance Coverage: lndicateth t7of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 0 Bond Ld Insurance Waive 1, 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 1hereby certify that all of the details and information I have sub entered) in are true and accurate to the (or A���akon is 'tall best of my knowledge and that all plumbing work an install n fo per and sue for this Bmfication will be in an complice with all pertinentprovisions of the Ma a se State P :� n j f e eneral Laws.. Type: of Plumbing UcAs`e" '*7 'own ens uTnDer Master B1100Journeyman ?,OVED (OFFICE USE ONLY I d,.' tG+.m. fir.:.ar....u,.. _,_..,. _.<! _'�..i __ _ _ t•_._... _ _ _ .. .._ _ _._ ._ ,_ _ t `- i -3'�. �f : ,2' _.. _ .. i ICIX The Commonwealth of Massachusetts O:flee UseOnlp l{/j P! ers(t b. - Department of Public Safety BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 1=3/90 Occupancy S Fee Checked (leave blank) APPLICATIOvvork N �be FOR mPed ERMIT �eTOPERFORM ELECTRICAL WORK Mat I "chuserts Electrical Code, S27 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 3 — City or Town of ���r �� ( �e _ To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 73 Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No ® (Check Appropriate Box) Purpose of Building Utility Authorization NO. Existing Service Amps 12-b 1 "03 Volts Overhead LTJ Undgrd ❑ No. of Meters c� New Service /,U o Amps/�f� /,.A 40 Volts Overhead 0 Undgrd ❑ No. of Meters �. Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work �Er/ % e�� t Z2 + V No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total RVA No. of Lighting Fixtures Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators RVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No, of Switch Outlets No. of Gas Burners FIRE ALARMS - No. of Zones Total No. of Air Cond. tons No. of Ranges No. of Disposals No. of Detection and Initiating Devices No, of Sounding Devices No. of Heat Total Total R'mDs Tons KW Space/Area Heating KW No. of Dishwashers No. of Self Contained Detection/Sounding Devices - No. of Dryers Heating Devices KW Local ❑ Municipal ❑Other Connection No. of Water Heaters KW Siznsf Ballasts ILooT Voltage No. Hydro Massage Tubs No. of Motors Total HP �lra:i i7 INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or i substantial (!' equivalent. YES•NO ❑ I have submitted valid proof of same to this office. YES or If you have checked YES, please indicEl ate the type of coverage by checking the appropriate box. INSURANCE [8' BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work $ /,'(,j O Work to Start• v 9 Inspection Date Requested: Rough Signed under the penalties of perjury: FIRM NAME1.Q Lc V1 Expiration Date Final td,i% ( /w - 8S M � LIC. No. 4,15 7,9 Licensee Signature LIC. NO. Address Bus. Tel. No.-�z7/� Alt. Tel. No.��j3 _Pits��-j58S; i 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 General Laws, and that my signature on thispermit application waives this requirement. Owner Agent (Please check one) I -W 4 4 7 L Date ... �3... �?....�.G�•••• ' ,c TOWN OF NORTH ANDOVER slow p PERMIT FOR WIRING �SSACMUSe pp O O This certifies that ................. i .................... ............. has permission to perform ............................ ............ . � N wiring in the b ' tiing of .......... ............................ ........................... G at......... .......................................................... . North Andover, Massy Fee.................. Lic. No............................................................................c ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 80NT{ Zoning Bylaw Review Form Sok ",�- • s•i6 OL k Town Of North Andover Building Department 27 Charles St. North Andover, MA. 01845 `" Phone 978-688-9545 Fax 978-688-9542 Street: Ma /Lot: M -- 0+1 Request: 17 5 o- Date: oi�"0- Please be advised thatafter review of your'A, APPROVED J DENIED for the following Zonin Zoning Item Notes A Lot Area` t Lot area Insufficient 2 Lot Area Preexisting 3 Lot Area Gampffes_ 4 j Insufficient Information B Use 1 Allowed 2 Not Allowed 3 Use Preexisting 4 Special Permit Required 5 Insufficient Information e5 C Setback 1 All setbacks comply 2 Front Insufficient 3 Left Side Insufficient 4 Right Side Insufficient 5 Rear Insufficient 6 Preexisting setback(s) 7 Insufficient Information D Watershed 1 Not in Watershed 2 In Watershed v 3 Lot prior to 10/24/94 4 Zone to )e Determined 5 Insufficient Information E Historic District 1 In District review required p 2 Not in district on and Plans your Application is v reasons: Item F Frontage. 1 _ Frontage Insufficient 2 Frontana Cmmnliac 4 Insufficient Information 5 No access over Frontage G Contiguous Building Area 1 insufficient Area 2 Complies 3 Preexisting CBA 4 Insufficient Information H Building Height 1 Height Exceeds Maximum 2 Complies 3 Preexisting Height 4 Insufficient Information Building Coverage 1 Coverage exceeds maximum 2 Coverage Complies 3 Coverage Preexisting 4 Insufficient Information T Sign 1 Sign not allowed 2 Sign Complies 3 Insufficient Information K Parking 1 More Parking Required 2 1 Parking Complies 3 1 Insufficient Information Kemedy for the above is checked below. Item # I Special Permits Planning Board. Item # Variance Site Plan Review Special Permit I Access other than Frontage Special Permit Frontage Exception Lot Special Permit Common Driveway Special Permit Congregate Housing Special Permit Continuing Care. Retirement Special Permit District Spec iecial Permit Watershed Special Permit Notes C Parking Variance Lot Area Variance Height Variance Variance for Sign Special Permits Zoning Board Special Permit Non -Conforming Use ZBA Earth Removal. Special Permit ZBA Special Permit Use not Listed but Similar Special Permit for Si n Other Supply Additional Information The above review and attached explanation of such is based on the plans, request for or information submitted. No definitive review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the applicant serve to provide definitive answers to the above reasons for this action. Any inaccuracies, misleading information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to be voided at the discretion of the Building Department. The attached document titled "Plan. Review Narrative" shall be attached hereto and incorporated herein bC y_ reference. Thebuilding department will retain'all plans and documentation for the above file. Building Depart tm ]ent Official Signature Application eceived Application Denied Denial Sent: /� d✓ �� o2n�bo If Faxed Phone Number/Date: Plan Review Narrative The following narrative is provided to further explain the reasons for the action on the property indicated on the reverse side: Fire Police Conservation Plannin Other ZoningBylaWbeniW2000 nt of Public Works Commission 1*1 0 O_W M o` N � 00 O� F: Q 7 fb y E ik C y • �` 11.1 n y Q I N 2g • Q2QCi U- -2Z. 2'. • yjQp _ . W °oohs 2y2 U W E U Tw W O�WC c0 1111 I. W W J ti LL Q Q J� Z1'" — m J L qM� . ¢azo J � W m $ (,DO tcl) E U i am to x t/1 m 12 Date.^. .�. fTOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........_ �. has permission for gas in the buildings of ....... at .. . 5 U. � ...... I Fee.? :.-.. Lic. No.......... . Check 4325 ...... North Andover, Klass. .......... . GAS IN TOR MASSACHUSETTS UNIFORM APPIKATON FOR PERMIT TO DO GAS FI. 7MG (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name h , ,S C New ❑ Renovation ❑ Replacement ®/ Plans Submitted 0' Permit # �,1 3 g -lam Amount $ --7_C-, 62 (Print or type Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. ❑ Partner. Finn/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ Ifyou have checked ye& please indigatefthe type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all ofthe 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 orm de�r �Pfor this application will be in compliance with all pertinent provisions of the Massach4s a Gas, C n Snepq Laws. (OFFICE USE ONLY) ature of Licensed Plumber Or Gas Fi tuber ! G Itter Liaerise Nurn oer Master ❑ Journeyman • • (Print or type Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company Corp. ❑ Partner. Finn/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ Ifyou have checked ye& please indigatefthe type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all ofthe 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 orm de�r �Pfor this application will be in compliance with all pertinent provisions of the Massach4s a Gas, C n Snepq Laws. (OFFICE USE ONLY) ature of Licensed Plumber Or Gas Fi tuber ! G Itter Liaerise Nurn oer Master ❑ Journeyman F ` Date..`.. .�... .. . NOR7p TOWN OF NORTH ANDOVER f 1 PERMIT FOR PLUMBING s � r t This certifies that ......../.. ...... �-!!................... . has permission to perform ......... plumbing in the buildings�o .. 1 r at ...... ....... � ................ .Noah Andover, Mass. Feel<'.... Lic. No.......... .. 1 ..l... . .......... . LUMBI G,, SPECTOR Check # AaerK.z � C/// MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO D ` PLUMBING (Type or print) NORTH ANDOVE/R,,MASSACHUSETTS Building Location�i ez' New ® Renovation Owners Name Date Permit S� goo Amount Replacement ® Plans Submitted Yes ® No FIXT11RES • _ — •' (Print'or type) �.�—' i Check one: Certificate Installing Comp y Name 0/k ®Corp. Address Partner. PS N `> Business Telephone — 4/ Firm/Co. Name of Licensed Plumber: /--) /r/ / -1 le J /- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Y Liability insurance policy ��' Other type of indemnity El 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 El I hereby certify that all of the details and information I have best of my knowledge and that all plumbing work anstat compliance with all pertinent provisions of the M a sed Type of Plumbing License se 4N ume� Master (OFFICE USE ONLY Agent in above application are true and accurate to the c�Petmi� sued lication will be in ptei 1 f the General Laws. Journeyman 0- Location 143 Gl'111 -/ c /Z No. o26 -abo 3�5/ Date `1 iS-,:)C,0,,,3 TOWN OF NORTH ANDOVER .. o ►o. s a Certificate of Occupancy $ r �'�s''•° U''tt' CNUBuilding/Frame Permit Fee $ sASE Building /Frame Permit Fee $ Other Permit Fee 513A) $ 30 TOTAL $ Check # 3 a 1 1 63,22 `-� Building Inspector W M z a H O z LL O ?z 7 O I— s I, z O U J CL CL I.i.. W a. Z C7 W _Q) a) N O Q O C LL R3 `�- U O .Q CL N O Z � U cu � c m — � c� � a) L TOS O V L m 0- 0 U ,C O Ci II. 7l >1 >1 C U ca CD m C: Q cu L O a) a) . o' E m C z cm, , cn a) 0 W W U U a W m H O z J J z O U J CL a W W J CL O U Z z V Q Z (D U) co Q co -o (D mO L) U) (i c c ca z, a) o m o 'C: o o � ami . W ncn♦♦ +�� V .� (D a) L > �- (6 L O O a) E N .0 (D (Q • C � (nC C CB L O) m a) cm U_ N w .0 � 5 O C EC_f C O Q c L = `cc — >+ O (Li • L- Co LL Q a V a) 0 0 p� m C� T c = �— a0 N p a� Q acsmc 0 C cB C L T U cu a Q) __ CO cn Z C W 0 L ca C m a O L O cB U Q) O L N .. Q) p E U) -II L1 Q) Q c U O L O E O n cm U Q O C O cu C cu +-+ cu N U C E J 2 Z cn'cn - N c m c N = L C L C C O L O 4 - OL C7)O OL_ C cm N N C < 00 C-0 �D M O m II U c M J M O _ cr O a] U O O L cc - n. : O 4 - CL U L o U L cU a ,_, o_ o a) ami ia m C- cm - cn m.— � L c O OL cz L O O L O Z � U cu � c m — � c� � a) L TOS O V L m 0- 0 U ,C O Ci II. 7l >1 >1 C U ca CD m C: Q cu L O a) a) . o' E m C z cm, , cn a) 0 W W U U a W m H O z J J z O U J CL a W W J CL O U Z z V Q Z (D U) co Q co -o (D 32 x 54 10/21/02 MON 10:21 FAX 976 682 9272 BARRY J MARTIN - MVAS LCZ) rS 2d 93 s,e¢- - 4-- 1 "—� W 004/005 , 1 i s N, 13 1 � 1 � r 1 i=IN ex/.'9 7-'1171 /7- 1,;FZ Tr X ItBRRaIr r= ruzz VNUROR "'P PLOT 1'"N too I= am lamer r= loww"Cr rig LarAWD ®x I!V THE Wr as MIN MD MT It DOES comm" WE iD'�7 �....� AU'.r��,a,�pPYe-� HOMO RBMJU'rlM R$r.Aae We samen FROM SrJWM & LOr 6.[N V " I FURM-9 CSRWr WAIT WS DFRU" i Is JVOV DRQ PW FOR / LOCAM JW 2W HARMAREA A8 soOIX OA 6r1'&fi r Ddra !°RIBP F'SR N dab - IVOT FOR eo' r�xaa�r �urerlox. ®�rrruDAar IxFrla�► JMWilACK SK0l 9ZJUkVG ORRVICES TA"N !'Rau BarrRrluc xWcnRos ee �eR� �rR��r 11AMOKS& /,;I -moo,0`a YASSACHUSCM 0100 I. I v O O j 3 A C�Ils O W ' •' o 0-0 to w 0 -cl oC) N Com.) - a v ER s'y z F'+ i� °L' O �a1i O a d Yy !� Z '0_' • S � a � Icy � y � U �i�-i F+ti.l z �e :} Rj� W= Ha � � � •o �o ti ,• oP�� o Z Z c• A � to C) 0 0 41 v v .pm -da ° to cd O r, 9 N U U O U z 0-.4 en �o c ot.x. N p O W O H ;Ln ,= v H ° ° o fn H o b o o • O W � C13 Q Location j No. T '1 Datej TOWN OF NORTH ANDOVER 4. i Certificate Occupancy $ of s�C" Building/Frame Permit Fee $ 30- N Foundation Permit Fee $ IV 0 4 - Other Permit Fee Perwl $ � .-- ;).)o) rer V .. TOTAL $ t Check # c23 16169 6169 ^ Building Inspector J=� TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: L4 DATE ISSUED: l SIGNATURE: AP Building Commissioner for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Propeaty Addr11es__s: 7 �`J� cS 1.2 Assessors Map and Parcel Number: Map Number Parcel Number �r� I 1.3 Zoning Information: Zoning Distrid Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided ReqWred Provided 11 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: L a e op 3 r 2 5,-,s�' ign a lephone Not Applicable ❑ License Number 1 �45- Expiration rate 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone T M z 0 0 z M 90 0 ic r M r r z ^/ Y IN SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction 0 Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition ❑ Other Specify /-'r-, ,'1 j Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by pennit applicant u t3?�FIC�ALUSE ONLY' I . Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 301— e $A W -30 , WO R (C u./ A 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 jzi �0 I C5_0 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, ,as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Name Signature of 0e/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIVIBERS iST 2 ND 3 t` SPAN DMIENSIONS OF SILLS DB/IENSIONS OF POSTS DIMENSIONS OF GIRDERS IIEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE EM North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S.150A.. The debris will be disposed of in: ( 6-c tion of Facility) ignature of Pe it Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through.the Office of the Building Inspector Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: �a k1re-, -y- IS City A) It,— Phone # JI am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address City: Phone #. Insurance. Co. Policv # Comoanv name: Address City: Phone # Insurance Co. Policv Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 andlor one rs' impnisonm t_as_wag-as_civil.penaltiesjn2beiomn-faSTOP WORK ORDER and a fine_af_($1D.o.0 )aiday.agakwnw- I understate th a copy of this ittatement may be forw7ded to th4Office of Investigations of the DIA for coverage verification. l do hereby 6Vrtify finder the pairs and Print y above is true and correct. Official use only do not write in this area to be completed by city or town official' City or Town PermiYUcensing. Building Dept []Check if immediate response is required .0 Licensing Board F1 Selectman's Office Contact person: Phone A- F1 Health Department F -i Other A � w° V') OF z co w° w C7 w°' w ¢ U a°' c� w z ►- rL w w cn Un 0 c c C N O V• 'a•o sa; :I cc m= O E = t _ t5 o CD ` =w N 0 CD L a'�1' E ca Ma73 rn _ COZ�-0 C :rSma c � N o Em7. ♦: C. V m Q� 2 : _ • : _y O m C: • O O t+ m 14 rlV y O v CO C O) m H m C C N CL. o $ e -mr W = Owl= M- N LA- FaevC Z votoacm O L* C. 2 o s O CL,- m zip CO 0 CD 0 s z o. CD y ® C CD CA I C � CD •_ An a' o •E m m C �� CD 0 ® O � 0 d CL c m .EL 0 CD C.3 N7 m •A C _0 0 U) W W crW LLJ _o a U W i -a A OZ �p O � o z r� v J CO 0 CD 0 s z o. CD y ® C CD CA I C � CD •_ An a' o •E m m C �� CD 0 ® O � 0 d CL c m .EL 0 CD C.3 N7 m •A C _0 0 U) W W crW LLJ _o Date ........ ,� . ...1'y�.. ..�. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ............................................C This certifies that ...... .1.......... has permission to perform Uiw '" e e C�c{ � r /C.�- ........................................ ... ............ ...... wiring in the building of .....10-e. t' / S °...... d./ .P. ............................. lam/ °�C iZ at—042 ...�.2..,�y.�...........0-�.............rv..�........................ , orth Andover, Mass. Feer ..!!.`....... Lic. No.. ,7.$..P.l................ .. !`... ' ���C Check # LECTRICAL INSPECTOR l 1 F'.� � 4434 6 ThF09"0AW'E9L2H0Fh&FS4CffU 'L+7TS Office Use only DEPARTMENTOFPIIBLICS4FRY Permit No. .41g�Z� r'. BOARD OFMEPREYEM70NP.WUTA77O N527CMR 12:1110 ' Occupancy &Fees Checked APPUCATION FOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street J Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes /© No (Check Appropriate Box) Purpose of Building L-0 M MPf�c12c / �� �j�C1 L° 'H' -�� Utility Authorization No. Existing Service vZC'�Q Amps �yQVolts Overhead !n" J Underground 0 No. of Meters New Service Amps / Volts Overhead [:3 Underground No. of Meters Number of Feeders and Ampacity —` -z)o "i Location and Nature of Proposed Electrical Work No. of Nghting Outlets No. of Hot .Tubs 1 No. of Transformers Total KVA No. of Ligktiog Fixtures Swimming Pool Above Below Generators KVA ground . ground No. of?eceptacle Outlets No. of Oil Burners No. ofEmergency Lighting Battery Units t No; of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones �s No.jof Ranges No. of Air Cond. Total �'} . Tons No. of Detection and 1`4o. iof Disposals No. of Heat Total Total Pum" Tons" KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained .. Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of Na of Signs Bailasis No. Hyd,oNMassage Tubs No. of Motors Total HP rQ 1 Ur'MXco Pu >a Laws Iha%eaamutTxtTdylmira=Pobcyni&gCa CaAmaWeritsmbstadialecguvAn YES NO j IhawsubnffidvalidpioofofmnelottiOilim YES rE7TNO � Ifywha%edxckedYES,plea9ein11+a#etheWcf'o &aWbydwckirgthe fflxVi*Il CE a BOND M&R E3;`, (fm EstirrtAW ValueofEkCltical Wade:$ ; .. . WaktoSl:ltt ` DA RaWesd Rot# Faral Sigttedutxfer�ieP�s_ -u j - FIRMNAME arr�l�'cT �� ( LioanseNo 37Z Lualsm —7Ce yn e - e-� � Sig�ueL+oaseNo �`� ►'h � �j BlWxssTdNa 7Y9 -3'N --- " �U� II t� aye r� ��f1�t , 0B c� Aa TdNo OWNER'S INSURANCE WArVM- I am a% ffi-li-mg-dimpatheitlslra�oeoo�aageaits leglriva astecpmadbyM CmaalLaves and trat my sigtt�taem the pami<at waits � tec�taanent. (Please check one) Owner Agent i� Telephone No. PERMIT FEE Name Name: The Commonwealth of Massachusetts 1 Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 1 am an employer providing workers' compensation for my employees working on this job. Comoanv name: Address Phone Insurance. Co. Policy # ' Company name: i Address Y Cifv Phone Failure to secure coverage as nequiredunder section 25A or MGL 152 can lead to the imposition, of criminal penalties fine up to $1;500.00 and/or one years' imprisonment.as vel.as_ci»I.penaltiessm-tbe-h mosafa-STDPIAIDRK OAR ar3d_afiaeaf 111aDD a understand that a copy of this statement may be forwarded to the Office of 1 ion. l ` Investigations of the DIA for verification. / do hereby teddy under the pains and penalties of perfury that the i OWniab'on provided above is hve aW correct. Signature pare Print name pbane # Official use only do not write in this area to be completed by city or town cfficiar City or Town Perrr>itllicensirw O Building Dept OGheck Y immediate response is i6quireri �=` � ; -,0 - ilcensiilg Board p selechildn's_ Office Contact person: Phone 1 Health Department ❑ Cattier Oil LU co In '.Uj W I tu — ul \ f ��\\\$ $ \ m m k \ cb \ 03 ca CD w IL V) COu- 0 u b A d V � a F `h W oz o F 5o W H � CdO S 0 u b V � a F oQ oz o F 5o W w� a Wo Uu V qd� a �A F� O 0 u b r �I W W Cd c. o c � o 0 CCc N t� OC -3 •Q C • O O •o� N � Ego ' r m �O. CL . N O r o0 u cm�CL.E r me o :®® a �_ C N O 3 r � c o .•�C ` N N O C • O 44 E m •`mo � 2 =�o cmO IL C Gn cm • � c :®moo CDCOD N CD o LU 10 LL •y m � N •ate LU c Z � m •N C* oe ®� O :v i•0 ® h •� co v c G L Z CD cD o. 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