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HomeMy WebLinkAboutMiscellaneous - 80 WOODCREST DRIVE 4/30/2018 (2)ll� Location Yo [err z,- �`�c IPi2 C� No. 16 Iq Date J NORTH TOWN OF NORTH ANDOVER • L .. A �e Certificate of Occupancy $ C14 t�' Building/Frame Permit Fee $ `' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 2'z'• Check # /a5 % f 166?0 _ Building 64pector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 1.1 ''Property Address: SPW// OQCbertG� _ 1.2 Assessors Map and Parcel J lo3 Map Number Number: P l Number tOr 1.3 -.Zoning Information:11 _ Zoning District Pr osed K6 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqlIired Provided Required Provided 1.7 Rater Supply M.G.L.C.40. 54) Public 0 Private 0 1.5. Flood Zane Information: Zone Outside Flood Zane 0 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHMAUTHOMED AGENT Historic District: Yes No 2.1 Owner of Record �rr�1/or�olu �a u/caz��r�5f Name (Print) Address for Service: t , Signature Telephone 2.2 Owner of Record: NaAie Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: License Number Address �jZ, 40,4 ;o/_ /177'FS Expiration Date Signature Telephone 1� 3.2 Registered Home Improvem nt Contractor Not Applicable ❑ Company Name �(J��✓ v O Registration Number 4 dl4m ow Addre4 ss O y r Expiration TD'ate Si ature Telephone In SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2506) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes ...... $ No ....... ❑ SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ AccessoryBldg. ❑ Demolition • ❑ Other ❑ Specify Brief Description of Proposed Work: 4k Jt Avv Al-eal 4UrA SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost Dollar to be (Dollar) ' y � � (3F�'ICIAL IiSIEa " , Completed bLnet applicant � 1. Building (a) Building Permit Fee �Q7• DO Multiplier 2 Electrical (b) Estimated Total Cost of .Ot7 Construction 3 Plumbing . GCS Building Permit fee (e) X (b) 3 D �--- 4 Mechanical HVAC — 5 Fire Protection 6 Total (14-2+3+4+5)` , ` .O U Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize ,%j}Xf �jJ')�� �'1/�1i/ to act on My bealf, in allafters elative to work authorized by this building permit application. ) l "Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1,J(% �%12iJ,Ji¢1y 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 Alhov Print N Si ature of Owner e Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 19T 2 ND3 KU SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHPVMY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING. CONNECTED TO NATURAL GAS LINE a t V� Location No. tw .9 Date tx .� --, TOWN OF NORTH ANDOVER F D • i • Certificate of Occupancy $ MAna IE<� Building/Frame Permit Fee $ swCHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ `3i&) � ! Check # / d?D ;I3 17314 Building Inspector ME � ej TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 50– BUILDING PERMIT NUMBER: DATE ISSUED: ye, SIGNATURE: Building Commissionefflfor of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: jl U O Numb, Parcel Number - 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage (ft) 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard -:T Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public 0 private 0 Zone - Outside Flood Zone 0 Municipal 0 On Site Disposal Sys,—.O SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT IStoric uistn-H—Te—s No X 2.1 Owner of. Record ��qk k1 Name (Print)•- Address for Service tur Telephone sc� 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES k1l L' nsed Construek"on Su sor: Not Applicable 0 PPz r --s Licensed Construction Supervisor: License Number Address /J-/(-7 Ila-7 Signa Telephone Expiration bate I 3. e e (KreltripA'ement Contractor- W gigCp4M Not Applicable 0 11AT C M, -u "Sly ch 7 Company Name Registration Number A re Expiraton Dfite St re —Telephone Ma M z 0 00 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 ....... 11 No ....... 0 SECTION 5 DesciA tion of Proposed Work check all applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) Addition Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: , Ile/r AM 414-711 r CA , SECTION 6 - ESTIMATED CONSTRVCTIOX COSTS Item Estimated Cost (Dollar) to be Completed b permit applicant �3FFICIAI. USIONLY�� x 1. Building f (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) X (b) Q ---- 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUH DING 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 Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVMERS 1 ST2ND 3RD SPAN - DIMENSIONS OF SILLS DIMENSIONS OF POSTS DI1vIENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUII DING ON SOLID OR FILEED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM y INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. ******************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT ! G`� 4 /�i �1-,�� PHONE - LOCATION: Assessor's Map Number o PARCEL SUBDIVISION LOT (S) STREET 262 %/1%b&11r_It- Or, ST. NUMBER 80 USE RECOMMENDATIONS OF TOWN AGENTS: I CONSERVATION ADMINISTI�TOR DATE APPROVED // DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm The Commonwealth of Massachusetts Department of /ndustnal Accidents Office of investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: Cit ty Phone # FI am a homeowner performing all work myself. `i�K 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. � f � / I Ci tv (� l c � Nig �l i ad z 6 Phone #: Insurance.Co. ____ _______ Policv# Company name: Address City. Phone #: Insurance Co. Policy # 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' imprisonment -as _well_as.civil.penaltiesinfheformjofa_STOP WORK_ORDER..and_a fine_of.(.$1.00.00)_ajday against -me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing []Check if immediate response is required Contact person: Phone #.- 0 Building Dept p Licensing Board p Selectman's Office 0 Health Department 0 Other ACORD CERTIFICATE OF LIABILITY INSURANCE DATE MM/DDNYYY 05/07/2004) PRODUCER (800)333-7234 FAX Eastern Insurance Group LLC 233 West Central Street Natick, MA 01760 Jr, Joseph Carroll THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED James Scott Peters DBA: Peters Construction 112 Vale Street Tewksbury, MA 01876 INSURER A: Harleysville INSURERB: Travelers Ind of IL 25674 INSURER C: INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD' INSRDATE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION (MM/DDNY) LIMITS GENERAL LIABILITY CB8G4305 01/31/2004 01/31/2005 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL & ADV INJURY $ 500,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 rl POLICY PROECT LOC J AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) BODILY INJURY $ ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ HIRED AUTOS NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO E AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND 679X361 10/12/2003 10/12/2004 WC STATU-oTH- TORY LIMITS EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 100,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ 100,000 OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS lob Location: 80 Woodcrest Dr. North Andover, MA Town of North Andover Building Inspector North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED R�'RESENTATIVE/J 25 (2001/08) // ©ACOKO CORPORATION 1988 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 disposl facility as defined by MGL c11,S150A. The debris will be disposed of in: L 4--&) &zq c i Location Facility) Si ure f Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector SUBJECT PROPERTY LEGAL REFERENCES MAP 103, PARCEL 75 80 WOODCREST DRIVE (DAVID M LINDA PAIAM) MARK NORTON AREA= 1.01 DE® BK 3539, PAGE 64 DOS =1992 SEB PLAN #6468 OCTOBER 15, 2003 SCOTT L. GILES FRANK S. GILES REVISIONS: SURVEYING SCALE: 1"=40' 50 DEERMEADOW ROAD a 40, NO. ANDOVER, MA 01845 (978) 683-2645 e-mail :FrankGilesSunrey@comcastcom 4 CERTIFIED PLOT PLAN OF LAND LOCATION 80 WOODCREST DRIVE NORTH ANDOVER, MA. DRAWN FOR MARK NORTON PARCEL 74 / ,,d.. �� Pry okd ,. ,f �r- Mi -- IV " w PARCEL 75 ITAY r 54A 26p 85 000 SF S g�55 50 / j THE PROPERTY LUM SHOWN ARE THE LINES DIVIDING EXISTING OWNERSHIPS, AND TH8 MM OF STREETS AND WAYS SHOWN ARE THOSE OF PUBLIC OR PRIVATE STREET OR WAYS ALREADY ESTABLISHED, AND NO NEW LINES FOR DIVISION OF EXISTING OWNERSHIP OR NEW WAYS ARE SHOWN. I CERTIFY THAT THE OFFSETS SHOWN HAVE BEEN DETE RA24ED BY AN ACTUAL TRANSIT SURVEY. X11 FRANK S. GUM, P.L� he - : 7" PARCEL 76 11 � THIS IS TO CERTIFY THAT I HAVE CONFORMED WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS IN PREPARING THIS PLAN S. GILES, P.L.S. REGISTRY OF DEEDS USE ONLY $04 (U;;Oo®RW F- si Eq * � a•. 0 a � a To a u' N D O v: Ea.. L chi alow � a a w° 2 U w rx° w -C, M a�' � i�. a.-� : gym � —Cd w w rig cn o cn �-J 0 z a 4 C4 y co .E CL r c O h O v y c O c a d h 0 co C O CL CD CL cma c cc � c CD Z� G. CIO c N W W oc W N of A X 2 � C To 1- u' N D v: Ea.. L C m O a = W i- -C, M N o a.-� : gym 0 V m 3�:2 m � N y W C �cEsiO. O � . cm m y m � O Om :� oa \•. o r. nC= m y O IS ca v o c a o C36 ? ` ,= _ �mIo ~ p y m w0.. � m W 00 .0-'s_ .._ •y O C LU d= Z o� L3 a m= oCM 1 _ A O y 9 O =�aJOEm> 4 C4 y co .E CL r c O h O v y c O c a d h 0 co C O CL CD CL cma c cc � c CD Z� G. CIO c N W W oc W N m IN ■o ■ is Im 13 m A 10 co V / co i Q G Z J� Z Ff C3 a: 1 C LUO i ^ z W • OL � - W c U) W > a D cc) ,o O ,o I � " ,o CD n 1 7 P i' I Ll Tn S /e .471 Lei s zr ao i d C cw r J } E i d fi Date... . �- J : -',/... TOWN OF NORTH ANDOVER PERMIT FOR- GAS INSTALLATION r t, This certifies that ................. has permission for gas installation _.oL.� ........... in the buildings of . "�?� !......................... at .-C'<-t s-(. , North Ando e , Mass. Fee —.�'�.. Lic. No.. Vin. !`.�,� `� � ,��..�... .. . GAS INSPECTOR Check # z 9' .4 a UNIFORM APPUCATON FOR PERNIlT TO DO GAS FPiUNVG (Type or prin NORTH ANAOMER, MASSACHUSETTS Building Locations V y O w,�) Owner's Name New LJ Renovation ® Replacement ❑ Date l °', 13, 40AI Permit # Amount $� i Mir k ►1 Plans Submitted (Print or type) Check one: Certificate Installing Company Name o S `l' (-cM P '� - - Y1 G r;;;v Corp. to 7 — G Address P. d ` G ox ~� �c:> ❑ Partner. Business Telephone 7 !9�- 6y v o Ss 1 2)- - ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter WMA i h C - INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves please indicate the 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 p Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. s Signature of Licensed Plumber Or Gas Fitter By. ❑ Plumber f �'7 °j "7 Title City/Town ® Gas Fitter License Number �IC�aster APPROVED (OFFICE USE ONLY) ❑ Journeyman W rA 4 U a v� W W (Yi OCIO 7 F x lJ 6 C7 a H F D z Z p F W rn F W O a a W C4 z U W �, v� W W. �. A F CW7 H z W F d z a Fx .» FW W >» O v, O w > z k. O H z W .] OCn H WWI z LL ¢z w � A t7 a UO C4 > A a H O UB -BASEM ENT BASEMENT ST. FLOOR ND. F L O O R RD. F L O O R TH. FLOOR [7T TH. F L O O R H. F L O O R H. FLOOR H. FLOOR (Print or type) Check one: Certificate Installing Company Name o S `l' (-cM P '� - - Y1 G r;;;v Corp. to 7 — G Address P. d ` G ox ~� �c:> ❑ Partner. Business Telephone 7 !9�- 6y v o Ss 1 2)- - ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter WMA i h C - INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves please indicate the 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 p Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. s Signature of Licensed Plumber Or Gas Fitter By. ❑ Plumber f �'7 °j "7 Title City/Town ® Gas Fitter License Number �IC�aster APPROVED (OFFICE USE ONLY) ❑ Journeyman ACORDCERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 09/10/2002 PRODUCER (781) 324-4118 FAX (781) 324-7189 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Medallion Insurance Agencies, Inca ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 180 Exchange Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 367 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Malden, MA 02148 INSURERS AFFORDING COVERAGE INSURED Alan Small man Building & Renovating 190 Middleton Rd Boxford, MA 01921 POLICY NUMBER INSURER A: National Grange Mutual Ins Co. INSURER B: Savers Insurance Co INSURER C. INSURER D: !`AVCMA/±cc MPK96738 INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EPFECTr✓E DATE IMM/DD/YY POLICY EXPIRATION DATE (MM/DD/YY1 Limas GENERAL LIABILITY MPK96738 10/01/2002 10/01/2003 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 500, 000 MED EXP (Any one person) $ 5,000 CLAIMS MADE a OCCUR A PERSONAL & ADV INJURY $ 11000,000 i. GEN' �AGC;REGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2 , 000, 000 PRODUCTS -COMP/OP AGG $ 2,000j000 POLICY ECj J ECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR 0 CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 00001828 10/15/2002 10/15/2003 EMPLOYERS' LIABILITY TORY LIMITS ER E.L. EACH ACCIDENT $ 50000 B E.L. DISEASE - EA EMPLOYE $ 500000 ;j E.L. DISEASE - POLICY LIMIT $ 500000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS BM Realty Trust is included as additional insured. I M-1 llY UMMR LCI ICK: VNI7VCLLMIIVIY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ."' EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESE TA E Jean D'Addar'o AC ORD 25-5 (7/97) FAX: (978)688-4165 ©A ORD CORPORATION 1988 ALAN SMALLNU --- - BVUEAI6ENEBAL ON I 190 Middleton ltd. Boxford, Mass. 01921 Phone/Fax: 978 -8&7 -6185 - Email: Smallco4@aol.com ,4k IMPROVEMENT MOUTH f y < ', + istr tioa: IQSSO Y' Exparition� OliD212QO2 Type IndiyAlvai t ALAN SNALLMAN �".� o✓ Rlaa Sra11�aR ,Y RAvfArA 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: (Location of facility) of Permit Applicant 9/3%3 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector 05/26/2003 17:38 19783721976 TFIT2GERALD PAGE 03 W d l�77I W26 1 W28 i 1i1 W BOWN83020 to `} 5�J-•, I � .. J w _ ml Q uj i a,_ I to- <<� W 0 4 Q J w m 46 r, BF1540 1/2x10CL x 182 Lu• m � i I 1— W Z w =—icn n0y�m Wpm WW(Qpm' m UNC ZO 0. > WWQWw_JU� UWJ U vs W�uJi�,-ujaow��a►z~°uaaao �J O Q~j d �a �F WDLL-M M�Q Wp�aw< h- N ch � cc LLJ ;z �cZi�UV0 ui Z2�C� m N W -- �--� own =wQi T z a►-J_5D� LU00 , NQ con ~ a= �_ >-mul4p-:lZWZ�G=�a��UUV) aaaCL o O +fir U' Z0IT WH,TFT <X< c0>WW H- G.. � Q W ZW Wnzo�&,Suow��,,Www�zwwzw 0UJQm QF— r S F- lL Q _ f- tdr� �Mm� O' J O:p.� --iJz:OWD� v ., 0-JOOQ60aI-J�Qgzaof 00 Z �3:unm ca U.c�-ouOQ� Wc7 �75l2h12003 17: 38 1979372197E TF I TZGERALD PAGE 04 v _.. .........- SN\ �--: QP 71)"A f7i -Ik4�%,nr)7 I T a! qj T;7. / F.P. ) F, T A r T P'O(V 'P7../W J - 05/26,12003 17:39 19783721976 TFITZGERALD PAGE 06 0 0 05/26/2003 17:30 19783721976 Y TF I TZGERAI_D PAGE 07 M IQ • a -01 0 Izvv Qj P4 0 co O co O Z O D CO) y .9 L CD C O v cc r.7 CA 0 L% CA C O L.7 O V co d CA C CO CM C O .0 0 � m m 0 co 3� Lftco � L O d d vs 4 C c ev � OG3 Z m CL CO2 C u� O w v cn � U G O w O T c U G w AG 0 U w .a p oG G x � O U w w w -C p a U cn C w a o w' G w Z w x w 2 v ar • a -01 0 Izvv Qj P4 0 co O co O Z O D CO) y .9 L CD C O v cc r.7 CA 0 L% CA C O L.7 O V co d CA C CO CM C O .0 0 � m m 0 co 3� Lftco � L O d d vs 4 C c ev � OG3 Z m CL CO2 C c c m c o L C H O C s& ' v O V �% 'O l0 C AP:rp 0 L m :.' :m m IlkC w m N c 42 c s S p� r m C E ;m acils -cam C e O m ` > = C H c0 N C O a�� : y m ' m qw:�..� cm ' C O C C m of w A O CO cc SZ 0 O ..: �c o C H Q y m C mr 9 = m I— N m CO) 'D.2 CD �_ .s c c H_ •� CL=cv v -p v N Z O V m m p m C 6/2 a 'mCos > 0:5 � H cc $ c.rm > • a -01 0 Izvv Qj P4 0 co O co O Z O D CO) y .9 L CD C O v cc r.7 CA 0 L% CA C O L.7 O V co d CA C CO CM C O .0 0 � m m 0 co 3� Lftco � L O d d vs 4 C c ev � OG3 Z m CL CO2 C E I O LLJ LLJ LL - N4 kN. cz 'A Z G z 30 6 -a V Erl -.3 m -V rn Cox rri :K: 0 LU ma cl \ Z a� �. ` v n ? n \ L6 4) ca r- c Ej LU z CD uj :1 > O !E cr 0 LL/-- ti 0 a: U) LLdD E 9 LU E I O LLJ LLJ LL - N4 kN. cz 'A Z G z 30 6 -a V Erl -.3 m -V rn rri :K: tai LU < LU Lu > �}'� IN z E I O LLJ LLJ LL - N4 kN. cz 'A Z G z 30 6 -a V Erl -.3 m -V rn rri :K: tai O z 0 U -j z 0 z 0 !;i Cl z Z) 0 U. cc 0 U. cc Lij IL V to 1m--1 r Lo4tion Nay, / Date"" NORTh TOWN OF NORTH ANDOVER A Certificate of Occupancy. $ BuildinVframe Permit Fee $ -- sACMUs - Foundation Permit Fee $. Othe,r Permit Fee $-'- r Connection Fee �Vy Wate�ection Fee $ TOTAL /�� $ f•D O Building Inspector r j Div. Public Works Location i No. / . Date 11/61 I61 Z- TOWN OF NORTH ANDOVER Jp Certificate of Occupancy $ � • RE{; Cts�// ��yy eeYy N�• ` + Buil ding/Fran'iPerhit J. ,VSACMUSEt Foundatiomgr �I F $ /fin. (:)0Other Permee � $ SewEN§oA t9d*f oftd& Water Connection Fee TOTAL / 'Building'insi ecto Div. Public Works (` PERMIT NO. O/ t I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. p � i l) . f4q Y / PAGE 1 MAP K-4O.LOT 000103 NO. __Parcel 000075 2 RECORD OF OWNERSHIP DATE BOOK PAGE 102407 ZONE SUB DIV. LOT NO. F— 10146_ LOCATIONPURPOSE 80�Woadcrest Dr_vej--N.—Andover OF BUILDING _ Single family home OWNER'S NAME Robert E. Webster NO. OF STORIES 2 SIZE 28 X44 OWNER'S ADDRESS 60 Woodcrest Drive, N. Andover BASEMENT OR SLAB basement ARCHITECT'S NAME James Bourgeois SIZE OF FLOOR TIMBERS IST 2X12 2ND 2X10 3RD BUILDER'S NAME M6 SPAN 141 DISTANCE TO NEAREST BUILDING 651 DIMENSIONS OF SILLS Dbl. 2X6 DISTANCE FROM STREET 381 POSTS 3-2" lally DISTANCE FROM LOT LINES - SIDES 301 REAR 3001 +/_ GIRDERS 3 - 2X12 AREA OF LOT 44,000 s. f : FRONTAGE 1871 HEIGHT OF FOUNDATION 81 THICKNESS 1011 IS BUILDING NEW yeS SIZE OF FOOTING 1211 X 2011 X IS BUILDING ADDITION no MATERIAL OF CHIMNEY Brick IS BUILDING ALTERATION no IS BUILDING ON SOLID OR FILLED LAND solid WILL BUILDING CONFORM TO REQUIREMENTS OF CODE yes IS BUILDING CONNECTED TO TOWN WATER yes BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER no IS BUILDING CONNECTED TO NATURAL GAS LINE es INSTRUCTIONS SEE BOTH SIDES PERMIT FOR FOUNDATION ONLY REGULATED BY PARA: 112.7 S.B.C. SAGE 1 FILL OUT SECTIONS 1 - 3 '- PAGE 2 FILL OUT SECTIONS 1 - 12 •� DATE: FEE PAID: ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MU T CO FORM TO STATE FIRE REGULATIONS PLANS MUSTE ILED A D?A PROVED BY BUILDING (INSPECTOR JDATE FILED ✓ -- - �0,x// ►�! - - SIGNATURE 04 AWN EtR OyAUTHO:tV& AGENT FEE �OS D� CONTR. L�I�C4tt PERMIT GRANTED 3 PROPERTY INFORMATION LAND COST $75,000.00 EST. BLDG. COSTEST. BLDG. COST EST. BLDG. COST PER SQ. FT. $55.00 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH 63-3163 9'37 y� PLANNING BOARD is BLDG. PONT FEE $- D( LESS FDA FEE- PERIAllT FOR FRAME/BUILDING DDE FRAME PERMIT $ 06-.60 " JAN 13 1,992 : f v - DATE: �.. FEE PAID:!!�l+.._ BUILDING DEPAF �_R-1 1. BOARD OF SELECTMEN IJP 'NV1d 101d S3OV1d3U SIHl '43SOdWIL13dnS '013 'S39VLI -VE) 'S3H:M0d H11M 'S9N1a11n9 30 SNOISN3W_Ia lOVX3 aNV S3N11 101 WOUA 3ONV.LS1a CNV 10-1 JOSNO1SN3W1a L:)VX3 MOHS1SnW NOIl03S SIHl zi AONVdn000 L 9NIIV3H ON I P'E P"L 1•W.9 D1a1:)313 110 SWOON dO 'ON L sVO Sd31V3H 11Nn O.1.H 1NVIOV6 6NINOI110N0:) 81V _ S631dV4 BOOM aOdV/\ 60 6.1.M lOH 'S105 B 'SW9 1331§ WV31s 'S10:)'8'SW9b39W11 Nand 61V lOH 03DbOd 3JVN6nd SS313dld 1SIOf DOOM 0NIIV3H it I `JNIWVbd 9 OOVO 3111 60o1d 3111 s3anixld NS30OW ON13Oo4 1106 a3MOHS 11VIS 13AVd 8 6V1 ONIBWnld ON I'll's NNIS N3HD11N A601VAV1 13S01� 631VM S30NIHS DOOM S310NIHS 11VHdSV 03HS 1Vld OaVSNVW j1-369WV9 dIH X 31"0 1'Xld ZI 'W6 131101 X1 UXIJ EI H1V9 11 VN19wnld O1 dooa S r-3dns 3a018 aOOd 1 ONINIM 3WVad NO 3NO1S A8NOSVW NO 3NO1S 'N19 a30NID a0 'JNOJ _I 80014 S 'S61S OI11V 3WV6d NO N0169 kdNOSVW No NDI69 —OSVI E 1 9 3111 'Hd NOWWOD 3WVNo onls J� A6NOSVW NO O�Jn1S ONIOIS '163,\ ONIOIS SOIS30SV O.rk(JdVH _'_ ONMIS 11VHdSV HldV3 S3IONIHS DOOM 313aDN0:) ONIGIS SOaV09dV10 saoold 6 II S71VM v W09 1.k1.9 ON %i °% %i llnd V3dV N3HJ11N Na300W S3DVld 3613 V38V DMV NIA V3aV .1.W.9 'NI 1N3W3SV9 £ £ Z 1 8 NI3Nn l l VM A60 Sa31d 631SV1d -(1d O. N\ VH 3NO1S 60 N0I89 3NId 'N.19 313dDN00 313aONOJ HSINId V01831NI 9 NOI1VONnoi Z N011OnUlSN0O S1N3W16VdV _— s301d40 AIIWVj lilnw 7 _— S31a0!S X AllWV3 316N SS AONVdn000 L cc 0 p W 0 Y U � C Z C m Q 60 fis 6s 6s D o o � } O c E w U 1 LLa E m o 0 O N m LL U U O p d +-` C m C Z m o E o 0 3 v c0' cc a. V U O C m m m Q F- N O m F- O m ti O W OJtR y+► cts U `� • "'��'�'' J Z tiM04 . •'� FORM U TOWN OF NORTH ANDOVER s LOT RELEASE FORM SUBDIVISION Parcel 000075 Book 02407 Page 0146 ASSESSORS MAP 000103- SUBDIVISION 00103SUBDIVISION LOT(S) Lot 54 PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET Woodcrest Drive APPLICANT Robert E. Webster PHONE 508-374-4511 DATE OF APPLICATION 12/02/91 TOWN USE BELOW THIS LINE PLANNIN CONSERVATION COMMISSION CONSERVATION ADMIN. BOARD OF HEALTH rii:E�Llil "5Ei1V`SlE1I�lEi1V ��2cao.�LS DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT 6197-F /WATER CONNECTIONS Re,( FIRE DEPT. DATE APPROVED DATE REJECTED REJECTED DATE APPROVED / DATE REJECTED DATE APPROVED h �% DATE REJECTED RECEIVED BY BUILDING INSPECTION DATE E IANI 1 3 100? I J` zlQ/ This form shall be signed by the agents of the Planning and health Boards, Che Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the Compliance of any applicable Town requirement or Bylaw. BAYFIELD DEVELOPMENT COMPANY, INC. • 242 Neck Road HAVERHILL, MASSACHUSETTS 01835 Phone (508) 373-3000 FAX (508) 37 4900 TO Ll7 e LIEUTEa of TURZEDUUL DATE ! — _,?y JOB NO. ATTENTION RE: iL- O � �✓ u✓e+t 17-3a - 9 (fp►4f e 1 S, - f .f -- 571-e ,e. ctf SV e f -W > WE ARE SENDING YOUttached ❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 17-3a - 9 (fp►4f e 1 S, - f .f -- 571-e ,e. ctf SV e f -W og a� f C d ^- THESE ARE TRANSMITTED as checked below: g For approval ❑ For your use > ❑ As requested REMARKS ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ For review and comment ❑ ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US 3 � D6 COPY TO SIGNED: J—Er-2 t ek to PRooucrzaoz a In, cruW, Maa O]471. if enclosures are not as noted, kindly notify us at once. . _ ALONG _ A W 11 § ( 4w ® \ �\ -0 m 'M 2 _ $ 6 -j o -JN Esq uj� J« �« Cnw o _ �a "UJo �, §x_ �� - QM u� _ a oma. �x� U. _ �� � 7% lz§§ �� _s■ > _ ad CL w\ s■� m G pn « _ (j §§° LL ���E b _ ��« z . a_m � ■t!K =2« � 2�.® k D — ZEWk C) ,.| W2 &- -Z Kf C) N U, o opi= o o I _ g a .§.- o a»z: _ � ¥ § § L � LA,k t©§ A�z z - o & s § �RLL, % § § ■ � moa a � § it Ifo / § X�� k s. D O "O C 3 0 � F04 F- Z CrN a 0 z 0 A m -v m L =z z O V) w J zz z Z 0 Q O Z D 0 LL cc 0 W W a ii U J >n cn at a W "' co g D LU W Q 1= i2 V� V r4 N A yy ti O t' O O O Q W N W W 66 z Z Z W W O z V h W o t m co T d =W V O V 0 w m cm W co W m Y O O L C Q U ii O C Q ii O 0 Q U) 1i O C rev Q M � Z CrN a 0 z 0 A m -v m L =z z O V) w J zz z Z 0 Q O Z D 0 LL cc 0 W W a ii U J >n cn at a W "' co g D LU W Q 1= i2 V� V r4 N A M ir LU w 0 9 O: C O: O 09 N LIZ J Q C ~ V JU O n I z M ir LU w 0 9 I W W LA- V) w _1 q v 0 v V L iU Z J m V O 0 N Z C w Q a w 2 m O LL L CC ui CL w Q � Q a O��s� O: C O: O 09 N LIZ J Q C ~ V O Lli W6u CL CL W o. W H F a. N ? z z LU 96 LU 0 to o u a o `A Z - W � z Z 0 m V � C m J a eo ui •(A m L1 3 J 3 V C Q Wm; � YC CC U ii cr c ¢o Q M FR P I- f I W W LA- V) w _1 q v 0 v V L iU Z J m V O 0 N Z C w Q a w 2 m O LL L CC ui CL w Q � Q a O��s� C .0 N LIZ C Lli CL V c a. 4) C .0 R C CL V c a. ow c to _C a o v 3 C � 0 m V � C a eo •(A C 0 z O Z V O LL IL Ir E%- cc cc Ln O' ru ti Ln Lil U U y A� �i N p � A U Lu G7 � a wi � A w w ci a W.3 C7 W cn F+ F wi a � cY Z fz, � w Qe w 3 y Q-) o 3 ZE y o w VO w W o WA vA Z ` Z -- U A vn a € • A p W Ra � c � � F m r N ON w xr w F-- C� w 0 D 2 z 0 CE m 0 w v 4 h -v ,710 AASZA Date. 40RTjj TOWN OF NORTH ANDOVER: PERMIT FOR PLUMBING SSACHU ...................... This certifies that . . . . . has permission to perform plumbing in the buildings of .................... at. . FO ..t! c? 9. ........ "A i North Andover, Mass. Fee./o. C`.... Lic. No.. I PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location A 4 r -Owners Name 41 Date Permit # Y Amount ' G Type of Occupancy New ®'` Renovation ® Replacement ® Plans Submitted Yes ❑ No FTYTTTR F. (Print or type) T Check one: Certificate In 11 C N �1 t S/rdr22c �9�' �� M Corp. stag ompany me Address 5 6 V /L Partner. . - YL.o a tJ -.e A`- `{ Business Telephone ©`Firm/C0. Name of Licensed Plumber: )13y—'�- Insurance Coverage Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �` Other type of indemnity ® Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent I hereby certify that all of the details and information I have su mitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and ' 1 'ons p ormed under Permit Issu for this application will be in compliance with all pertinent provisions of the Mass Sta lu bing Cod and Chap 142 of the 6eneral Laws. By:t a ot Licenseaum e Type of Plumbing License Title City/Town icens um ber Master Journeyman APPROVED (OFFICE USE ONLY • (Print or type) T Check one: Certificate In 11 C N �1 t S/rdr22c �9�' �� M Corp. stag ompany me Address 5 6 V /L Partner. . - YL.o a tJ -.e A`- `{ Business Telephone ©`Firm/C0. Name of Licensed Plumber: )13y—'�- Insurance Coverage Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy �` Other type of indemnity ® Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent I hereby certify that all of the details and information I have su mitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and ' 1 'ons p ormed under Permit Issu for this application will be in compliance with all pertinent provisions of the Mass Sta lu bing Cod and Chap 142 of the 6eneral Laws. By:t a ot Licenseaum e Type of Plumbing License Title City/Town icens um ber Master Journeyman APPROVED (OFFICE USE ONLY Date ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ......y.. .......... ....-............................................................ has permission to perform ..................... wiring in the building of ....�:........ . ..........,.y........................................................ at :::'..... , North Andover, Mass. Fee-�....... ..... Lic. N4:57 J21...../.. ..................................:- :................ �/ J B�.ECTRICAL INSPECTOR Check # /�/�H 5363 V BOAROOF 'MASSACHUSE775 uC AMY REGULA77ONS527CMR12-00 Office Use only Permit No. C'S Occupancy & Fees Checked APPLICA77ONFOR PERMffTO 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)' Date 1 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) o CX) Q0 0 Owner or Tenant /1 N 0 At o n Owner's Address Is this permit in conjunction with a building permit: Yes [ZI—No a (Check Appropriate Box) Purpose of Building IDC V 01/ r W C ' Utility Authorization No. Existing Service 0 AmpsVolts Overhead M Underground No. of Meters New Service AmpsVolts Overhead ED Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work CV1 Qir t(' No. of Lighting Outlets 3 No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above 1:1round Below Generators KVA round No. of Receptacle Outlets , 3 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 No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- ri /// N C hmuarloeCovera� Ptua�actbdten�gtritanaLsol'M�adit�IsGena�alIaws '`IhaveaamaltLi*'A.yh>aaa=Fbhcymcb&gCm4)lee CowWoritsaftillapmlat YES NO Ihave% niwdvalidptoofofsmwoDthe0ffi= YES If)mhavechadedYES, pkasemdicalethetypeo dFrki1Wdr box 0 E INSURANCE M BOND GIBER WodcroSWd 7A4a 74 4 tlesmd Sigreciurld?rTiePa ' afpecjuty. HRMNAME Lioersee l 7-;3w Fi .f` (rj7�Wy SigMlute qiNSe may) Estirrwd VahleofF =cal Wodc $ Rough Final hvl " _ LketseNo. _ Lio3serlo BusillessTel. No. 7 7t-/ ,OURM�` • ` •— ` Alt Tel. Na OWNER'SINSURANICEWAIVER;IamaumdattheLioersedomnothawdrirmuanoeonvaageormst>)staltialegr4erltastecltlredbyM CellaalLaws and that mysignahlteonthispetmitapplkahonwam' this Mquitinem (Please check one) Owner Agent Telephone No. PERMIT FEE $ signature of Owner or Agen