Loading...
HomeMy WebLinkAboutMiscellaneous - 80 CHRISTIAN WAY 4/30/2018N O I �p � O = � A I � � Z O �2 ODG O -�b—mi nd a au ao3 Sldduag :ajoN *** :pasoi3 a;ecunmiad —;air uolsuaixa muma ❑ .pasoi3 OWCMullad — g ain;� 'ZIOZ `Si;sn3ny g3nonl_3uipua;xo put, 8002 `Si;sany uo 3uiuui3aq pouad 3ui i31P nb ail 3uunp „a0ua;sixa Io ;00330 ui„ SEM;t,t� leAOlddv io Ilmod Sue `a;up uoT;glTdxo olgt,oildde asimlo to s;i puodaq slgaA Ino31o3 `spua;xa SIlgaT;EWO}nE;ay at; `sAOl;daoxa pa;TiuTl TIiA� ijladold p 0130;uauidoianap So asn at; 3utula0uo0 sasua0g pue s;tuuad Ii'a o; uoisuaaxa lea i -Ino ai;uuto;ns ue $uigsiigE;sa iq asodind sill slaTplii3;0�r uoisuapcg;tuuad at; pug tflanooal 0turou000 uua;-3uol pue t[vAolg gof oloulold o; si lou sit;3o osodmd aus -ZIOZ3o s;oy o' tR 30 8£Z Ia;dzt03o SL P- VL Suoi;oaS Xq papuaIca PTu OlOZ3o s;oy 5Tl3o ObZ la; ego3o £L I uoi;ooS Sq pa;eal0 sem;oV uoisua;xa nw-im au El uoi;t,otiddg;tuuad aTl uo pa;u;s �}luo 3uglt,;sui ail Io Iaumo ail Iailia3o;sanbol uoilM aTl} uodn pa;t,umua; oq ll-qs Ilumd y •asnt,0 olquuoseal Io3 pa�tuuod oq Iluts suom3o uoi;olduioo Io3 Oml3o uoisua;xa tm `uoi;uoiiddu ual4ilM uodn •pouad iguoui-ZI 3uip00aid ail 3uilnp possa13old;ou sgq Io paouaurmoo jou set 3uom pazuoq;nu ail;t,Tl pouiuua;ap set oqs Io --aTr3rPHgAmlpug-pauopuuge saliM3o-Io;oodsiToglWq-pauiaali-oq Xi?ui pug Si;ini;au uoi;am;suoo 3uto3uo3o aun;ail o; se pa;tuiil oq-huts s;tuuad Z£ § `EN 'a "I'D'Yd ui Palinboi su )IIoM aq;3o uoi;aiduioo 3o uoT;uoggou at; Io3 olgisuodsoi oq lluts f44uo tans •uoi;t,otiddu ;tuuad aTl uo pa;u;s not;ulodloo to Ting `uoslad *Tp o; ponssi aq Iluts ;ruuod leou;0010 ue `Z£ § `99I 'o TJ 'W o;;uunslnd pa;ulodde solim 3o io;oodsul uu Xq p0;doom uaaq set uoi;uogddu ;tuuad u la}nr Tuio3 paqu0sald ail uo POIg oq huts suoi;t,oilddu pug `Tlluomuoiut uoD oil;not3noiq; uilo3lun oq llegs 3uuim3o uoi;t,llu;sui3o aoi;ou Opinold o; uug3 uoi;uoilddu;ruuad \ / atl `Z£ § `£bi '0 ' I'J'Y�I3o suoisiAold ail Tlin1 aaut,plo00u TII :g aing § o0'Zi 2IZ1ID US s;uaaipuauiV apoo igata;aaig e71asntaussgyV ZIOZ Xf�` N'. 9 90"'b'1 Dat... .. .. ................. 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING NJZ� . Ir This certifies thatodazala, ........ C7 Azl.c .. .......................... has permission to perform ..... .. .................. wiring in the building of ZRIM ...... ............................... ........... /,'North Andover, Mass. FeeX . . ...... Lic. No. ........ . .. ................. ELE RICAL INSPECMR Check 4/—/av� 8 � /� QQ// �//� l,ommonwea& o f rrlamacka6etb Official Use Only — c� Permit No. !jam ..UeParimeni o1ire �erviee9 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 (VC), 527 MR 12.00 IN (PLEASE PRT IN INK OR TYPE ALL INFD�TION) Date: ova //D City or Town of. N d/7 (YO!/ P/l . 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) S'Q C A A /6 ^,q A -t We t- / Owner or Tenant y>rJ ,S .p/j fOt^ ,�^ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building J J lue l�I r79 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: Completion of the followingtable maybe waived by the Inspector of J;'fres. 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 ❑ n- E:] rnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners o. of Detection an Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g �No. of Waste Disposers eat Pump Totals: ''umber """".. ' ons .......... o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ElOti Connection No. of Dryers Heating Appliances KW Security ystems: No. of Devices or E uivale .t No. o aterKms, Heaters o. of o. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: Z `t' h Attach additional detail if desired, or as required by the Inspector of ff"ires. Estimated Value of FActrica Work: �0120. 0'O (When required by municipal policy.) Work to Start: a gO� 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. T�1,:2 undersigned certifies that such cover e is in force, and has exhibited proof of same to the pe mit issuing of��X CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) Gel#eall� " Cty/ I certify, under the p ns and penalties of perjury, that t e information on this application is tru and complete. FIRM NAME: nZ /C� / (' L Ty� LIC. NO.: Licensee:����1 /`jam//�/l/L Signature �%� L_/� :i LIC. NO.: (If applicable, enter"exe p " in 16e7ine -sen tuber line.)U�� Bus. Tel. No.:� Address: l� Alt. Tel. No. *Per M.G.L. c. 147, s. 57-6 , security work requires Department of Public Safety "S" License: Lic. No. _ O 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 Signature Telephone No. PERMIT FEE: S �a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations l ... 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): x1el A&r Address: City/State/Zip: Phone #: — %%ry-1,3/.2 A;Vyoan employer? Check the appropriate box: 1 • Lm a employer with �_ 4• E]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 forme in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. �• We are a corporation and its ❑ required.] 3. F-1 I am a homeowner doing all work, officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8.. O'Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other * Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and Job site information. Insurance Company Name: G PH ae Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: C t, 3 Al' "i W q!!�1 City/State/Zip: GI/!�� 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 fine 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 hivestigations of the DIA for insurance coverage verification. I do hereby certify and r th pains and�penalti Zr* that the information provided abov is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #:. N° Je j t} Date (.q /1— � "pR'M TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� This certifies that ..... ✓..!"'"` ..... has permission to perform PtpAf`. plumbing in the builds of . ................... at..8 9...C. nc`.....r�"`.....w'4` �. , North Andover, Mass. Fee3 Lic. No.. . ....... PLUMBING INSPECTOR Check # /3 1? WHITE: Applicant CANARY: Building Dept. PINK: Treasurer DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIO KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [INO i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE OF INDEMNITY 0 BOND DI OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are and that all plumbing work and installations performed under the permit issued for this application will be in c Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME IZ S ..�'?�_ P { LICENSE # 3% rate to the st of my knowledge all ertin provisi rr of the SIGNATURE CORPORATION [9#13 3 `ffi PARTNERSHIP 0# LLC E COMPANY NAME tADDRESS /30 X CITY__.___.._.......STATE ZIP TELj _ r-1-0 - FAX CP/�'_ 3S'' EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �. CITY �c�,JF3�ti MA DATE PERMIT # JOBSITE ADDRESS !� ��1/2r` `A'� Lt/� OWNER'S NAME 1 k" POWNER ADDRESS , TEL _ FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: ©1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NOD FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM I I I I DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIO KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES [INO i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE OF INDEMNITY 0 BOND DI OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 10 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are and that all plumbing work and installations performed under the permit issued for this application will be in c Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME IZ S ..�'?�_ P { LICENSE # 3% rate to the st of my knowledge all ertin provisi rr of the SIGNATURE CORPORATION [9#13 3 `ffi PARTNERSHIP 0# LLC E COMPANY NAME tADDRESS /30 X CITY__.___.._.......STATE ZIP TELj _ r-1-0 - FAX CP/�'_ 3S'' EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Pty .,d S oiryd City/State/Zip:'n U. 4, Phone #: Are you an employer? Check the appropriate box: 1.D I am a employer with `Z 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. [-Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: u Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:_ 371, C ��Z t } t �ti l�/' City/State/Zip: `7'i 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 fine 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 DIA for insurance coverage verification. t do hereby cel undgf the panes and !ties of erjury that the information provided above is true and correct. Date: Id A// Phone #: l 2� b 8cy 4 rz--L a Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: J Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-577-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,gov/dia ti The Commonwealth of Massachusetts Otiicc Use only permit Sar Department of Public Safety occupancy & Fee ouleted BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 12M 3/90 (leave slant) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance With the Massachusetts Electrical Code. S27 CMR 12:00 R (PLEASE PRINT IN INR OR TYPE //AL-�L I,NFORMATION) Date_/�� City or Town of , (.��4'4- To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) �%f (�D�v Av' Owner or Ienant 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 AmplV Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and A --pacify Location and Nature of Proposed Electrical Work _'or_ La ,` 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. YESK h0 C3 I have submitted valid proof of same to this office. YES ® NO C].If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE J"0J BOND ❑ OTHER ❑ (Please Specify) �y p' ation Date) Estimated Value of Electrical Work $ /'�� //,//�� ///% Work to Start Inspection Date Requested: Rough /i 4104&( Final Signed under the enalties of perjury: /% FIRM r1A21M �+ L/ !� L T / C & C' . LIC. NO.�_3 Licensee J lee�/ iJA Signature LIC. NO. S9 3 Address 16 Z 0 eus. el. No. j20 (a Alt. Tel. No. 014NERIS 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 this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent No. of Lighting Outlets No. of Hot Iubs Nd(. 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 Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained No. of Ranges g Total No. of Air Cond. tons No. of Disposals 114o. of Heacmps Total Total PuTons No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Local Municipal El [:]Other No. of Dryers Heating Devices KW Connection No. of Water Heaters KW INo, of No. ot Si ns Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP ,` 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. YESK h0 C3 I have submitted valid proof of same to this office. YES ® NO C].If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE J"0J BOND ❑ OTHER ❑ (Please Specify) �y p' ation Date) Estimated Value of Electrical Work $ /'�� //,//�� ///% Work to Start Inspection Date Requested: Rough /i 4104&( Final Signed under the enalties of perjury: /% FIRM r1A21M �+ L/ !� L T / C & C' . LIC. NO.�_3 Licensee J lee�/ iJA Signature LIC. NO. S9 3 Address 16 Z 0 eus. el. No. j20 (a Alt. Tel. No. 014NERIS 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 this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE S Signature of Owner or Agent ` Date .................................. a NORT1f °f t `° :•'"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �,SSACMUSE� Thiscertifies that............................................................................................. has permission to perform............................................................................... wiringin the building of............,....................................................................... at............................................................................... , North Andover, Mass. Fee—..., .............. Lic. No..............,.............................................................. ELECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Location r S� '-WA&-I) A4y 4' No. N N i3 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation �e $ Other Permit Fee', fid' $ Sewer Connection Fee $ Water Connection &)Bi $ " TOTAL $ l ��? ilding Inspector Div. Public Works F Ilk W N H a � a � W m Z 0 z Z 0 J W_ a• m 0 LL O 0 0 WW N 00 LL N 11a Z Z ►i '11 0 0 z N I I� N K W m m F N F C K 0 0 F J LL W LL F 0 W W � N m b Z < a N in fll W Z Y U I V -M N Z C 0 } J F O p W J K < Z O F N p 0 z 0 I LL 3 Z U 0 0 F LL LL 00 0 0 J m F LL < FW N < O I m F V C O IL �\ `9 ~ N W ylF W < W C Z F Z ( Z 0 0 N Z < N H N w U Z¢ F W z Id W = O < Z Z U DI �O 0 W F Z LL r 0 J LL 0 W �I = i L W 1 a I m I Z n JAl 0 ( I 0 Z N G UO \ < L 0 ( O N 9 �' 2 m 8 ` } • CJq O L I n 4 d m W 0W W IL 0 d F- o U F 0 U 0 U f a W W C1 0 OmJ 0 m J m J m a U Z W � Z 2 Z V I > LL i � m < F J � O - O \V z = i L W 1 a I m I Z n JAl ! ! ( I 0 Z N o j m i Z W t7 L 0 ( O N to L� o ` M O L I n m ( W 0W 10 la ! N I � 0 I U W 1 a I m I Z I 0 Z o j m i Z W t7 y m W >a O N L� o M I n 1 0W 10 j LL Z O 0 m LL Z I > LL i � < F J � O ,Z 0 IA W IL d DOx C)-1 NrN zm im • Do mzz Cv3 �km D 3nm 010 (nv:E pi m MX -( z D Ion moo �z_ mm3 'a0Z �m M 0 m C z m r rDO -1c)r vm0 r -� DSD ?z :i v =v N ;aD 0z 10 mm m -n �m D0 3 m m n O �v v O ADOvDm(A D„ 0m OO,CAmcODA OcmO D D D0 Z D G. pO OO n►0 D vc3 INz0 0 v a v D w m m D+ O o NAnn A O A .M 3 w A 0 0 A N- ; r 0000 0 0=- 0 Nv 00 2 �= c 0 A m mZ 0 ~ O N Z ZZZNZO A 0 ti W° T- T C >„ DDNS N; > a T ` pe nOn 7� 0'- NGiN3= p 3Om3: > 3 Zn <{ 0 >DNOZ�N T< 0 N O < j N ~ 0 ��; 0 A '^ l! 0 z � O O - r a c m> D Z D p 1: 0 O v .. �- 3 r 0 y z D p- A D (� f p m y O y D 0 v D y D n Z N O D 'O n D O (0 3 O T T_ A z _T Z C v z A V x D D _v Z 00 X C O N _ N O H 3 A T r a G x _ A _ n A 2 g A Z x T< A y Q T n -0 L. T A m Z o o N v T° -V, AW C s m A zY-�� D m Z` D AO m NN -Din Z Dtiz-i m=OA 2N 0� OOZ23Z 0 0wT-< An mA ,y `” rZ0 �" ,inn-� 2 T Q n 0 ~A 2 X�zz �n v c �^ F A z N O OZD A D Z An T " -1('� AA ~T A T D m D O A T T Z N X 0 O Z I I I I-• I I I I I p A Ai ci 00 A '" Z IIIII" I I Iill!III ililifl� IIII � DOx C)-1 NrN zm im • Do mzz Cv3 �km D 3nm 010 (nv:E pi m MX -( z D Ion moo �z_ mm3 'a0Z �m M 0 m C z m r rDO -1c)r vm0 r -� DSD ?z :i v =v N ;aD 0z 10 mm m -n �m D0 3 m m n O �v v rA cd a O E M r r O O z rA cd c c m c O C c O N cc ' c O _V V Q'a C. R A coco c p i r E a T : L r.. v o c 40 0 • V ,� m J_ aim Q C c w :. E mCIO m a N .c V f(Am W N y O O m _ V ♦: A cD j Qzs CRO•D"6-COD= c c 32 A' c H Q �: yJ p : m 3 �:�y0 0 ¢= cZ �`o c CL S M:a OCOD N H o y 0 o1- a� s LJJ p .� y.., c •N C E W eZ S •uj E V 'p V N O om s g G* O. O> O.0 S eyo bO l�J V J w P-4 a O E � O O v C C � 0.= GM H O .O U m m O4.4 O 0. ca 0 Ccc vCc J� -Q. C Z � O O. CO2 O" O C 0 � w m u m v w 6 Q o w° c/)w° d U ii w' w c� cn w w CO co cn c c m c O C c O N cc ' c O _V V Q'a C. R A coco c p i r E a T : L r.. v o c 40 0 • V ,� m J_ aim Q C c w :. E mCIO m a N .c V f(Am W N y O O m _ V ♦: A cD j Qzs CRO•D"6-COD= c c 32 A' c H Q �: yJ p : m 3 �:�y0 0 ¢= cZ �`o c CL S M:a OCOD N H o y 0 o1- a� s LJJ p .� y.., c •N C E W eZ S •uj E V 'p V N O om s g G* O. O> O.0 S eyo bO l�J V J w P-4 Z-7 C) Q W U) z O U O E � L O O v C C y 0.= GM H O .O U m m O4.4 O 0. ca 0 Ccc vCc J� -Q. C Z � O O. CO2 O" O C 0 Z-7 C) Q W U) z O U FORM U - IAT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ***************Applicant fills out this section***************** v/ m&,r F12zC/ l V C_ &s� -wi L,,LICANT: Phone LOCATION: Assessor's Map Number Sub ' "ision n ` Street l� /! e1J17q'YI w Parcel Lot (s) St. Number Q V ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Ins actor -Health Septic Inspector -Health Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved % ,5 Date Rejected Received by Building Inspector Date I APR 14 1987 NDR T H ANDOVER BUILDING DEPT. MORTGAGE SURVEY PLAN LOCATED I ' SCALE'/"-- 4o1DATE S',$"7 I� t-1 •r SLG/LES R.L.S. NORTH ANDOVER, MASS. 20R a .. / 14S_oo' _ CH NST14-N WAY TO 8 ITS T/TLEINSURER, THIS LOT /S INA FLOOD HAZARD ZONE. I CERTIFY THAT THE OFFSETS SHOWN ARE FOR THE PURPOSE OFFSETS SHOWN OF DETERMINING ZONING CONFORM/TYSc GSI. LES `^ � CONFORM TO THE OR NON CONFORM/T Y WHEN CONSTRUCT 90 ' 13970 {° C STt ZONING BYLAW OF AND ARE NOT TORE USED TO ESTABL /SH ��0"4 Lp . PND _ PROPERTY LINES. 11 4-11.187 1 For Family Fun! Ma40 intenance Manual for Our Valued Customers 5" w C) cn cn n 0 0 cn Cc .* =r CD CD cr CO2 C-2 CD n CL C2 m CD -0 =r== =r CL -0 cL IS Fn - CD O =rw tio CD 0-0 C2 • X 3E =r 321 CD c:1 40 MS C2 ca mn cc a 'o a Er = CL aom - co o =r = CD CD CS CD CL 0 CIRD s mom: CL go CD 3E .5 r =r CD CD CD RL 00 - CD.v co Amo' CD CD co fA 10 = CD dm: 5"o CL."s C.) C2 o co C2= O cl) cn cn by oP 0o0 cpcl O 1 0 ml "� CD CA C/) O CO) Cl) CD rz a = CD 0 COD =. tz ar— mm 0 CL ca rz 70-1 q CD 0 CD PC CL CD C-) CD CD CD C) cn v CD co) m CL CD CD CO3 C:) CD CA CD 10 CD O '-n CD :q > C) CD r- 5" w C) cn cn n 0 0 cn Cc .* =r CD CD cr CO2 C-2 CD n CL C2 m CD -0 =r== =r CL -0 cL IS Fn - CD O =rw tio CD 0-0 C2 • X 3E =r 321 CD c:1 40 MS C2 ca mn cc a 'o a Er = CL aom - co o =r = CD CD CS CD CL 0 CIRD s mom: CL go CD 3E .5 r =r CD CD CD RL 00 - CD.v co Amo' CD CD co fA 10 = CD dm: 5"o CL."s C.) C2 o co C2= O cl) cn cn by oP 0o0 cpcl O 1 0 ml "� CD C/) rz tz rz pm PC m H 0 9 woe_ PW O "� CD woe_ #i Ll ter}. 1C'�•�'1 rt a � �i.�iS i•8e «i. 'L1 Y y .. i ....,_ .'.^rte:. ..� V d Ll ter}. 1C'�•�'1 rt a � �i.�iS i•8e «i. 'L1