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HomeMy WebLinkAboutMiscellaneous - 799 TURNPIKE STREET 4/30/2018S King Design Associates, Inc. ARCHITECTURE PLANNING INTERIOR DESIGN 10 HIGH STREET MEDFORD, MA 02155 (781) 393-0400 FAX(781) 393-4228 Date:December 7, 2010 To: Gerald A. Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, MA 01845 ROUGMNG INSPECTION REPORT RE: Leonard Dental Offices at 799 Turnpike Street - 1st Floor Phase I - Ortho Bay Area Dear Mr. Brown: I inspected the project noted above today. The following has been done to date in compliance with our documents: . Exterior Insulation, Rough Framing, _Rouab P1 umbi ng and Rough Electrical Please call me if you have any questions. Thank you. Sincerely, King Design Associates, Inc. David A. Farmer, ATA Architect 97b Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 2. This certifies that ...... V ......... Al ..................................................... — has permission to perform ......... .......................... 4 —15-97ec....................... wiring in the building of ............ �P4/-Y2f) ....... .................... at ..... 35.9. Pz-i. F ...... Sr' ..................... North Andover, Mass. Fee -1/4/4 ........ Lie. No. llk7 .................. 42kzioi .. �. Check # 37- ELEcmcAL INSPEM0 A Commonwealth of Massachusetts Official Use Only Department of Fire .services Permit No. �% 7� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFOTION) Date:- aDl� City or Town of:Ar To the Inspector of Wires: By this application the undersi ed gives not' e of his or her intention to perform the electrical work described below. 'Location (Street & Number) '% �� j �/ h k - .5/ rP p i ,, Owner or Tenant �!h �q C�� rpp �7 Telephone No. �7*- Owner's Address � � � � Is this permit in conjunction with a building permit? . Yes No ❑ BLDG PERMIT # Purpose of Buildin i Wi, S -02 1~' 14 o „ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 110 Co'm letion of th Ir- Il bl e owing to Li - No. of Meters No. of Meters No. of Recessed Luminaires ,5/0 No. of Ceil: Susp. (Paddle) Fans may be waived by the Ins ector of Wires. No. of Total _ Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of LuminairesSwimming Pool Above ❑ In- ❑ o. o mergency ig mg rod.rnd. Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches a No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons 9 3 No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained Totals: "' Detection/Alertin Devices No. of Dishwashers Space/Area Heating KWLocal ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices Equivalent No. of Water ters KW No. of No. of or Data Wiring: Si ns Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: O� Aaacn additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: a &, JWO. (When required by municipal policy.) Work to Start: 11-11,2010 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. CHECK ONE: INSURANCE P" BOND ❑ OTHER ❑ (Specify:) I cert fy, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: i n ti q•Qplt Signature LIC. NO.: �a Address:ble, enter "exempt" in the license number line.) 191 e. -4L�4 Bus. Tel. No.: J,4/ - 2 71 '-Di fij!�. / Alt. Tel. No.:g7* *Per M.G. . c.147, s. 57-61, security work requires Department of blic Safety "S" Licen 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 Signature Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: �►,, ELECTRICAL INSPECTOR - DOUG SMALL r 1. ROUGH INSPECTION: Passed - Failed - [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 2-- /D . A' Ae ri .9 A e til 107 W- s A ves1y,5 r -ow- 6-- AP, -'z- r7 -1-C 3_1W__11 2. FINAL INSPECTION: Passed - [ V Failed - [ ] Re -inspection required ($50.00) - [ ] Inspectors mments: (Inspectors' Sign ure - no init gals) Date 3. UNDER GROUND INSPECTION: Passed -`[� Failed - [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - �initials) `� �Da /i 4. INSPECTION - SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed - [ ] Failed - [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date i/ 5. INSPECTION - OTHER: Passed - Failed - [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: 19 (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. lixThe Commonwealth of Massachusetts Department oflndustrial.Accidents OfJ1ce of Investigations 600 Washington Street Boston, MA 02111 qu www.mass.gov/ciia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectriciansIPlumbe>rs Applicant Information Please Print Legibly Name (B.usiness/Organization/Individual): Address: City/State/Zip: Phone #: Axe you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. 0 Remodeling . 8. ❑ Demolition 9. ❑ Building addition 10.C1 Electrical repairs or additions 11.C1 Plumbing repairs or additions 12. F1 Roof repairs 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new'affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for• my employees. Below is the policy and joh site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip.- Attach ity/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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a flue of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby certify under the pains andpenaldes ofperjury that the information provided above is true and correct. Si --nature: Date: 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. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 11 ContactPerson: _ hone #: 11 a 9891 Date ...... .. f ;v�``° *o- TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ..../ ..................l'�� S�Sj!itS ............... has permission to perform ........... Vic. z `l ll� v wiring in the building of ........C)./? ........... .......................... at ....... .�� Tizk Q/k ... S. '".................. , North Andover, Mass. } Fee ...... Lic. No.S ? �. .................... Fa.ecr"INSPEC70R� / Check #'ego .ti Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 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 IN INK OR TYPE ALL INFORMATION) Date: 1-11— 11 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. Location (Street & Number) -7 q 1 T urtV P% Ke 5+ / ST F-1 . Owner or Tenant D?-. 5e Le on o. r' D Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 1, Purpose of Building bCr\ i Ct J O f -f i CQ G-hoI F� No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: V eta rc o o e (7q ce Q lg (/-, S y S 4-e -.-% Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- El rnd. rnd. o mergency ig ing Batt No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS . of Zones No. of Switches No. of Gas Burners o. o e ec on and o�rj Initiating Devices No. of Ranges Tota No. of Air Cond. ons No. of Alerting Devices 1 No. of Waste Disposers Heat Pump Number Tons J.KW........... ........... of Self -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local [:1Municipl ❑ Other Connectiaon No. of Dryers Heating Appliances Kms, Security Systems:* No. of Devices or Equivalent No. of Water Kms, 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. 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 i rance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Lotnel anfl Pr -0 �frn 'S f :Tntc LIC. NO.: /5-I`7 C Licensee: S C61t' Signature uC /I c akdlL, LIC. NO.: 579 D (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: S`08 —875 -6Sov Address: P.O. (30 )C 21a.1 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires 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 a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. << n e+F Location " ' r ! ��'� / ��� S No. /33 Date 0/-/3 o a NORTF TOWN OF NORTH ANDOVER ` A Certificate of Occupancy $ `7SSACHU <� Building/Frame Permit Fee $ s Foundation Permit Fee $ Other Permit Fee $ S �~ TOTAL $ Check # 1 ac/9 15854 Building Inspector Jl The Commonwealth of Massachusetts Side Yard State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards Massachusetts State Building code BUILDING DEPARTMENT The Commonwealth of Massachusetts Side Yard State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards Massachusetts State Building code BUILDING DEPARTMENT 780 CMR Required APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number: Date Issued: 3� Signature: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION LI Prope Address 1.2 Assessors Map and Parcel Number: kAd L� O✓1 i lL2 S�i^� U 0\q/' M1F U 1 --Map Number Q _p Parcel Number IA Z6ning Information: � I D ' 1.4 Property Dimensions: (� C Zoning District Proposed Use Lot Area (sq) Frontage(ft) 1 6 Rnildino Snfr.arb iR N Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided 107 Water Supply 9M.G.L.C.40.4 § 54 1.5. Flood Zone Information: Information:Zone 1.8 Sewerage Disposal System: Public 0 Private b O Outside Flood Zone Q Municipal O On Site Disposal System 2.1 (l -of R --A MA S A - WV Name (Print) 1"'I'a �^ Address: Signature Telephone '7 �) - ZLy 2.2 Authorized Agent: Name (P e)l T/O /314 b ry L4'6- 14 A- P l ' 7,7 Signature Telephone 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: t4A/ IM Address 3.2" Revered Home Improvett%nt Contractor: Company Name 1.4 Address 1997 Not Applicable Q License Number Expiration Date -��3 • /vii Not Applicable 0 Registration Number Expiration Date SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT [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 W No SECTION 5 - PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature Telephone Expiration Date 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 5.3 General Contractor Not Applicable 0 Company Name: Responsible in Charge of Construction CLW Address 7/ rel G rON �i �- � �• � � � [Signature 1 Telephone f/ 7R- �6 3?1-3 /oho �ZL . f SECTION 6 - DESCRIPTION OF PROPOSED WORK check all applicable) New Construction 0 Existing Building Accessory Bldg. [3 Demolition 0 [3 1 Repairs 0 Alterations Addition Q I Other [3 Specify Brief Description of Proposed yc s✓ ' -4eA 1,V 6 W*6 A Assembly A-1 A-4 A-2 A-5 A-3 IA IB Q Q SECTION 7 - USE GROUP AND CONCTRTTC'TTON TVP>~ SECTION 8 - Building Heigh and Area BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels Floor Area per Floor s Total Area s Total Hei ht ft SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 USE GROUP Check as a licable CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA IB Q Q B Business Q rPvi,aPrl hyla 7rRo 2A 2B 2C 3A 3B Q Q Q Q 13 E Educational [3 F Facto Q F-1 F-2 H High Hazard (3 I Institutional [3 I-1 I-2 I-3 M Mercantile 0 R Residential 13 R-1 R-2 R-3 4 5A 5B C) 0 0 S Stora e Q S-1 S-2 U utility Q Specify: M Mixed Use 13 Specify: S Special [3 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 CMR 34 SECTION 8 - Building Heigh and Area BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels Floor Area per Floor s Total Area s Total Hei ht ft SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes [3 No 0 SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT ' , As Owner of subject property hereby authoriz ✓ to act on my behalf, in all matters relative to work authorized by this building permit application. lir D?� Signature of Owner Date rPvi,aPrl hyla 7rRo SECTION IOb - OWNER/AUTHORIZED AGENT DECLARATION A G/ coj-vry I-- ' , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print N 5ignatulpf Owner/Agent iul SECTION 11 - RCTTMATPn (0XT4ZTDT Tf rTlIT lf%0 c 54 / 4 Date Item V Estimated Cost (Dollars) to Official Use Only be completed b permit apWicant 1. Building jI (a) Building Permit Fee T Z' 0 Gt Multiplier 2. Electrical (b) Estimated Total Cost of 3. Plumbing -�, Construction from 6 Building Permit Fee (a)x(b) 4. Mechanical HVAC 5. Fire Protection 6. Total = 1+2+3+4+5 '70 Check Number 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: (Location of Facility) Signatue #' ermit Applicant �/� 0' Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector i 5' ■ 23'-2" '-10"x 5'-0"10"x 5 -o" T/T 1-10" x 5-O"'. "x 5-0" 0 0 O a 3-( �D �o y =� � o y b� b m CL N �- 00 -400 ;s x"oc"0 x„oc ;c .0-TE"V /V MO /L —.Z-,EZ I LE S x "oc"o ;5 x "oc J -t � J A U O co to O b a a J S x "oc"o ;5 x "oc J -t %.'Ol 23-2" 51-011-:=t 3-0" 7'4""- i 9/e -Coar�re o1,1&"cfuwe& BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 016468 Birthdate: 09/15/1936 Expires: 09/15/2003 Restricted: 00 JOHN M LUCENTE 71 FARMCREST AVENUE LEXINGTON, MA 02421 Tr. no: 2953 Administrator Cl) m 71 C/) Cl) m W d d O CA 'C7 n� 0 c H Er C7 CD 0 CD CDa y. CD CO) 0 O CD 0 CD O C• CA O Q N = n OCD co y O H 0 CS O T Z =r -O y' „_,► Cdr m HCL 0 T ? CD a Cv = mC/) CD O m y p O � � m O > > .0 G Cm•) .a.� OumO :lp n C CO y'! W C=2 Cp .Z CD n s oO �..�y 11J N CD :r4� :4 CDH 991 - 'ZI �Ci o moo. Z 7 CD o :.► 0 H .ter O C%a CD c CD w m CL �• :®�Zco, s Q 0 c p M � M mw z z � cn y 7� w LCl w n C gj C Tcn C 0 r b In CLp T evrAO x Q 0 c N° 2320 Date.... 14 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that............................................................................................ has permission to perform.. `�' _ r ., ,...,.., .........:... ......... wiring in the building of ...... n� at . flq....17-, ......... ......... .............. North Andover, Mass. 35 rte-- Feer .............. Lic. No.............. ..... ......................ti ........... ^� � LECTRICAL INSPECTOR Check # �-�.�"-'� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THECOMMONWE4L7HOFMASS4CHUHETIS DEPARTMFIYlOFPUBLICSAFETY BOARDOFFIREPREVEM70NREGUL4TI0NS527CMR 1Z-00 Office Use only Permit No. cl;?1317-lel Occupancy & Fees Checked - 57;7 `� APPLICAWW PrIlR PERMIT TO PERFORIVI 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) Date. U , —,1000. Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street 8 Owner or Tenant To the Inspector of Wires: Owner's Address 6e! 6e! /9 //) t°/ Is this permit in conjunction with a building pepit: Yes r7 No r7/ (Check Appropriate Box) Purpose of Building eolvk Utility Authorization No. Existing Service Amps/ Volts Overhead a Underground No. of Meters New Service Amps �� Volts Overhead M Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work��Owm JeYD 71 r, No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below rJ Generators KVA ground ground 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 No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps 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 Mo. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs 1 No. of Motors Total HP OTHER • rmtrmwkAWIM IhmeamnatLiabtltyhsrmmPbbcyur]ukgCmTkic�CmeaWcris ma mf&ala>t YES NO Iha%e&kmkmdvddpttx>fbf bthe0ffi= YESj/� NO IfywhmedxdWYFSspfeasertdc*thetypeofoaaagebyd gthe rDc. �=� 6 it CE BOND OTIfR (P6mSpeafy) EsnedVahredUmfticalWuk $ Weeko)Slat �hspecIcnDateRata Final - ®� FIRMNAME 4 I/ IioaseNa L _T , !J l M G' W,6 Q Signahn f L= seNo42 BtsimTdNa Aro# %` %� J%��9' CD/1 �� r ./% �/ AkTeLNa OWNER'SINSURANCEWANER;Iamm=d atlheUc=doestthemsuraner truss ksWtWo wala>tastepWbyivbwdnsoCa)edLaws andthatmysigsttl cnt spamitappkwmwa'pAsthismw'ff m t (Please check one) Owner M Agent Q Telephone No. PERMIT FEE $� Date,,,?—.,,f .e�l N2 4333 "ORT" TOWN OF NORTH ANDOVER ? �i ,r .... + O PERMIT FOR PLUMBING SA NUS This certifies that K < �.! i....': = Z-- '. `...... .... . has permission to perform:'`.__ r!� • • • • • • . . plumbing in the buald-ings of .. �!, : . . ......:' � ......... at.7,P . i //.. • • • -`�!"`" "�%i No h Andover, Mass. Fee.. Lic. Nbr(f ......::.�-:!.';' ..G -- ..... . f '4' PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location Owners Name PPermit # © Amount TypeofOccupancy New Renovation ❑ Replacement ❑ Plans Submitted Yes ❑ No ❑ FIXTURES A (%- mt or type) Check one: Certificate Installing Company Name ❑ Corp. Address ❑ Partner. s . 0202 Business Telephone W 3-6? �� ❑ Firm/Co. Name of Licensed Plumber r f— //QiC/rir�T/ Insurance Coverage: Indicate the twe of insurance coverage by checking the appropriate boat Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver I, the undersigned, have been made aware that the licensee of this application does nothave any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and informatiogl�have bmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work aons ed under P Issu this application will be in compliance with all pertinent provisions of the Mass 1 apter 142 of the General Laws. By: T—ig—na== ot Licenseaer Type of Plumbing License Title ��3 d ❑ City/Town icense Numner Master Journeyman APPROVED (OFFICE USE ONLY .