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HomeMy WebLinkAboutMiscellaneous - 805 SALEM STREET 4/30/2018 (2)J 1 Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ../'�.���.../ <./. !.. . has permission to perform ..%�e?��c�.nun �� plumbing in the buildings of . 6— at..-�l�n? ..7...... orth Andover, Mass. Fee✓?2 4 .. Lic. No PLUMBING INSPECTOR Check # i�� MASSACHUSETTS, UNOFORM APPLOCATIO 4 FOR PERMIT TO 00 PLUMS8NG (Print or Type) e ., =— 20 Permit Building LocationOwner's Blame Type of Occupancy New ❑ Renovation ❑ Replacement V Plans Submitted Yes ❑ No ❑ FEATURES Installing Company Address Business Telephone 2 9 g5-1 ?a" rdame of Licensed Plumber-- INSURANCE lumber Check one: Certificate Corporation u Partnership C Finn/Co. INSURANCE COVERAGE: I have a curve . iability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please _indicate the type of coverage by checking the appropriate box. A liability insurance policy SF Other type of indemnity ❑ Bond L OWNERS ANSURANCE WAIVER: I art 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: Owner ❑ Agent ❑ t. nereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to he best ofmy knowledge d that all plumbing work and installations performed under the permit issued for this application will be in copliance wi all rti nt provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By igna u s icenseaum,.�- rifle Type of License: Master i Journeyman ❑ City/Town License I\umber1, ve APPROVED OFFICE USE ONLYI -10 ( z ! i to }_ to U7 _i r<' ! rE) >- O L �_ 1 z til CO UJ E D 0 co d [Z n rn w 1- >- U < M f W C4 G LLj Z z Z Cr ► u Z 0 �CC �QJ tz < S w¢ �' ° tti O o a z w!f-o—'_ d W O¢ LL 0 vO < i ; LL cn l O [SUB-BSNiT. 'BASEMENT � j�•' ! t! fl I�J� 1ST FLOOR ' pp =2ND FLOOR ;3RD FLOOR 14TH FLOOR 5TH FLOOR ( t E ! i i t 6TH FLOOR( j iTfH FLOOR A - ; STH FLOOR a _ Installing Company Address Business Telephone 2 9 g5-1 ?a" rdame of Licensed Plumber-- INSURANCE lumber Check one: Certificate Corporation u Partnership C Finn/Co. INSURANCE COVERAGE: I have a curve . iability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please _indicate the type of coverage by checking the appropriate box. A liability insurance policy SF Other type of indemnity ❑ Bond L OWNERS ANSURANCE WAIVER: I art 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: Owner ❑ Agent ❑ t. nereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to he best ofmy knowledge d that all plumbing work and installations performed under the permit issued for this application will be in copliance wi all rti nt provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By igna u s icenseaum,.�- rifle Type of License: Master i Journeyman ❑ City/Town License I\umber1, ve APPROVED OFFICE USE ONLYI 78,,5 Date. �l�/......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ."vzvv/",v ii ......... ... ......... . ................. ;�P6,m 6��l has permission for gas installation 491, * 4 --*— in the buildings of .... A'CSZO� S I., ........................... at S'q. ZAI. . ..... I /I North An over Mass. Fee.,K .... Lic. No. AZY2 =�� ..... GAS INSPECTOR Check# On^/- MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAb-Fi i i five r-- . (Print of T I Mass. Date I C� _ t Permit sr Building Location /) � . K' M � 1"T Owner's Name -Fy/1 Py= k2Aras Type of Occupancy New C Renovation ❑ Replacement Plans Submitted: Yes Q No n Installing Company/ Name s-mmr:w i< ns' 10t mbr�"Utic Check one: Certificate Address_ po ,4)x//g9 Corporation .2652'x_ r� it /1l H 6 7V ❑ Partnership Business Telephone 11L %�� , �',� 1 QFirm/Co. Name of Licensed Plumber or Gas Fitter /Aldj,cs» INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. tat. Yes � No ❑ If you have checked yes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy F Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter i42 of the Mass. Generai Laws. and that my signature on this permit appiication waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed undet the permit issued for this application will be in compliance with all pertinent pro isions of the usetts State Gas Code and Chapter 142 of the General Laws By Tgk of license: rifli► ` t umber Signature of Licensed Plumber or G s iller 7ftle Gasliitter Master License Number c?fsyci ( +iyi i owr journeyman �PPROtirED (O IC U5 . NL 01- t a cc cc MENEM ONNOMEMEENMEMEMEN Ems Installing Company/ Name s-mmr:w i< ns' 10t mbr�"Utic Check one: Certificate Address_ po ,4)x//g9 Corporation .2652'x_ r� it /1l H 6 7V ❑ Partnership Business Telephone 11L %�� , �',� 1 QFirm/Co. Name of Licensed Plumber or Gas Fitter /Aldj,cs» INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. tat. Yes � No ❑ If you have checked yes. please Indicate the type coverage by checking the appropriate box. A liability insurance policy F Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter i42 of the Mass. Generai Laws. and that my signature on this permit appiication waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed undet the permit issued for this application will be in compliance with all pertinent pro isions of the usetts State Gas Code and Chapter 142 of the General Laws By Tgk of license: rifli► ` t umber Signature of Licensed Plumber or G s iller 7ftle Gasliitter Master License Number c?fsyci ( +iyi i owr journeyman �PPROtirED (O IC U5 . NL 01- t ACORD CERTIFICATE OF LIABILITY INSURANCE 4/1 2oi1 PRODUCER (800) 258-1776 FAX: (603) 882-1843 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Minuteman Group 90 Main Street ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 487 LIMITS Nashua NH 03061-0487 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Insurance Co. 39357 T'& W Plumbing & Heating, Inc. INSURER B. Acadia Insurance Company DBA: Simmons Plumbing & HVAC INSURER C: 11 Railroad Avenue INSURER D: noo're INSURER avrs v.�o ix ' f`/IVFAAf`FC MED EXP (Any oneperson) $ 5,000 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. AGGREG TE LIMITS SHO MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDCN POLICY EXPIRATION DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR 680-693SX92A 3/30/2011 3/30/2012 PREMISES E, occurrence) $ 300,000 MED EXP (Any oneperson) $ 5,000 PERSONAL& ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE I MIT APPLIES PER: rrtvvu%Ta-%vrvirivr iaaia 9 / nnn nnn X POLICY JECOT .LOC AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) B ALL OWNED AUTOS SCHEDULED AUTOS CAA0387253 3/30/2011 3/30/2012 BODILY INJURY (Per person) $ HIRED AUTOS ✓ NON -OWNED AUTOS / s - BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO • OTHER THAN EA ACG $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S AGGREGATE $ OCCUR CLAIMS MADE DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS LIABILITY WCA0387252 3/30/2011 3/30%2012 X TO YLIMITS OER E.L. EACH ACCIDENT $ 500,000 N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? If yes, describe under 3a states: MA, NH Officer (s) Included E.L. DISEASE- EA EMPLOYEE $ 500,000 SPECIAL PROVISIONSb.k, E.L. DISEASE- POLICY LIMIT I S -500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS I Town of North Reading NorthvReading,/MA 01864 f.1CoRn 94 /9nnitARt SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL .LU DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE AUTHORIZED REPRESENTATIVE Katthew Serodio/JOANNA © ACORD CORPORATION 1988 INS025 (moe).oaa Page 1 of 2 01 0 - The Commonwealth of Massachusetts Department of fndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 +vww tnass.govldia Workers' Compensation Insurance Affigavit: B_ udders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �� ^n©^�S Address: P. 0 ' R�-oX )19 �/ c City/State/Zip: Qt�;,�,roatc. 0 �' Phone #: Are you an employer? Check the appropriate box: 1. ED' am a employer with 20 4. El I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors - p •- -- - - - 2. ❑ t am a sole proprietor or partner- -`-' -listed on the attached sheet._$_.:.__ `J`., 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. r_1I 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 requirea. j l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling _ $. F Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.0 Other *Any applicant that checks boX #1 must also fill out the section below showing their -workers.' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name or the sub -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensad6n insurance for my employees.. • Below is the policy and job site information. n Insurance Company Nam( Policy # or Self -ins. Lic.1. Expiration Date: • - 1) f _ r U c:,o a rlrirocv• , ��(®�® f"d) City/StatelZip:� • fb'xf�/I�P/,yU' N ©10?.� JVV J1W Auua vu... - 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 ttp 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. I do hereby certiokynder the p#rs and penalties of perjury that the information provided 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: 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 r 9 1 2 3 Date. ?AA.... TOWN OF NORTH ANDOVER 0 ' PERMIT FOR PLUMBING This certifies that ! ......3.. .'j. ^ has permission to perform . f� ,//7�er� Z. plumbing in the buildings of ../'�!�/..'�c�✓�'�,S ......... at ...emr........ ; .- , North Andover, Mass. Fee. 71,.SZ�. Lic. No..�?�arU PLUMBING INSIFECTOR Check # r 'W 1`�1hSSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING � (Print or Typc) Date 20 `_ Permit !l uil�i�:, Location���- Owner's Name Fti a K0 Type of Occupancy ks) Nor v ', R(novation ❑ Replacement FIXTURES Plan .Snl,miur-rl V., r. h:., . _... _ Cora? ;:;- Name�.)r/ iirI0ilJ Y�(lYi7%�;`<: v flt� ri(` Check one: Certificate i Corporation C456 ❑ Partnership o Firm/Co. L..._r:st: Piumber i liebi!i: insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. -tom: n rindicate the type coverage by checking the appropriate box. _ .. policy � Other type of indemniry O Bond ❑ 1:'.411'cl?: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. =._t my signature on this permit application waives this requirement. Check one: Owner O Agent O of Owner or Owner's Agent that 211 of the det_'ls and information I have submitted (or entered) in above application are.true and accurate to the best of my knowledge bi �'orl: NA insta latiom performed under the permit issued for this application will be in compliance with all, pertinent provisions of S to e, in odee and Chapter ]42 of the �ieneral Laws. Signature of Licensed Plumber Type of License:Master ❑ Journeyman -._ ......:D :G U5= ON! 1'; License Number Ir' Wa w Cac SM CLAIMS DEPT. January 03, 2011 Commerce InsurancesM The Commerce Insurance CcmpanysM Citation Insurance Company SM Members of The Commerce Group, Inc.' 11 Gore Road, Webster, Massachusetts 01570 (508) 949-1500 www.Commerceinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MA 01845 RE: Our Insured: FRANCIS R KOZL`RAS Property Address: 805 SALEM STREET Policyk MH6266 Date of Loss: 12/23/2010 File#: WMR210-THHV39 Board of Health or Board of Selectmen Town/City Hall Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. JANE SMITH -CIC Telephone: (508)949-1500 Ext: 15339 Claim Representative I, Property Toll Free: 1-800-221-1605, Ext: 15339 On this date, I cause copies of this notice to be sent to the -persons indicated above, at the address above, by first class mail. January 03, 2011 4` cmmGro Companies CIC 254 (Rev. 4/95) COME GROW WITH US MAIL 569 Location No. Date TOWN OF NORTH ANDOVER .. 9 Certificate of Occupancy $ 's Eta Building/Frame Permit Fee $ s�GMUs Foundation Permit Fee $ Other Permit Fee TOTAL Check # 18429 U Building Inspect/ IYA TOWN OF NORTH ANDOVER t BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING r g 0 MAP, Ink BUILDING PERMIT NUMBER DATE ISSUED: b SIGNATURE: i Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: e 65 D 6 J/3 Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use 1 Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard 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 ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: Si' tature Telephone 2.2bwner of Record: r Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ 1"4- J . LA ";?-A 14ensed Construction Supervisor: a� � License Number ru �K n G� �� ' (/ A0 rens 7® 1 � l r � —e Expiration Date ,6 — C/O ( Sfinittke Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1' `wl,?l 1y C Clsrla, a r�ti. 16:L i�� 2 Company Name G f9✓1i�° �' j -lei A . Registration Number ddre Expiration Date Si nature 4elephone M M z O 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 checkau licable New Construction ❑ Existing Building 5,o"' Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: �/ S� 9-i/ AF % O J ! /(/� /J�i' /�i 6,-: C,&y j �L %�C' �'%�P 1�7. S -UL r-CdrF4.-ev 71 •c reoa IZ , SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by 2ennit applicant CIAt;USE ONLY „ 4 . 1. Building C, 2 / Z — (a) Building Permit Fee multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) Aq er.;� 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Z -- Check Number SECTION 7a OWNER AUTHORIZATIO 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/A THORIZED AGENT DECLARATION f subject I, J /1/' -Z--4 as O4;;� property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and bel of J A Print Na - 57 SiNature of O ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 s 2 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE e .�1 LICENSINC Department of Public Safety &.04 5 - � n Board of Buildin ReRulations One, Ashburton PYa c e I M 1301 Boston, Ma 02108-16108 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 04/20/1951 Restricted To: 00 - BOARD OF BUILDING REGULATIONS 1.1cense: CONSTRUCTION SUPERVISOR Number: CS 008628 Birthd?ite-.04/20/1951 Expireo: 0412Q/20.06 Tr. no: 21051 Restricted: 00 Tr, no, 19514 VAL J LANZA 34 BIXBY ST REVERE, MA 02151 Acting , cwnrnwooner Board of Building Regulations and Standards* Massachusetts Home Iniprovement, Contractor Registration Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvemelit-Qq-Titractor Registration NEW ENGLAND CUSTOM DESIQN, INC. - Val Lanza 226 LOW ELL ST. WILMINGTON,' MA 01887 9 Registration: 102467 Type: Private Corporation Expiration: 7/2/2006 lu Update Address end return card. Mark reason for cha"nge. r)P.I.r.Al -, -;nu. : nwu.n I M 91 AriAddress n Renewal F_ ­I Employment r Lost Carc m m m m N m mm c Cos d CD d 'v O St y d O C2� C � S C C. = y a� 10 o m o p O CD O CL r� c� =r and CD CDo C CD yCD� d O co) � O CD � v COD Cl '0 Z co � o � co 0 CD c^^ n O cn 7� cn C� o� O cn O cn cn c s 0 0 s • m 0 m a_ _ m m m c 0 _ Go O CL y H cg-oa m z aaa: y m CD ao m Cos s -c m mommy CA O3 o = =oo M. Zp m =r�7 ao = _ CL mmCOD - �Pro to V! am 00n� (/)',.1J rm7`:m • : y y mm _ O m o40` moo. O► aa: 'h G m o O cl y 1; mo' s: d 0 0 ?m N .� : Wim: mm: o CM: (n p (/)',.1J 0 w QGq cC=M: QC�Q � m (n p (/)',.1J w QGq QC�Q "Jd Qro '�7 n � Q�q 'h G O cl '17 Qq d b GoGo � o I I z 0 0 H 0 0 c 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 at: is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section 10A. The debris will be disposed of in: J/ C -,X -*t %ee'tS&1,1 S 7- 7 c7 L/ ;1-1X�ZT4t . S7' i"Wz1-P- °sem r-r� Fire Department Sign off: Dumpster Permit (Location of Facility) 'Z� Si Permit Applicant Date