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HomeMy WebLinkAboutMiscellaneous - 815 JOHNSON STREET 4/30/2018w o ao ocl D X X o Z cn o o 4 z o cD o� o m o -i Date.....". - TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that has permission to perform AAA % 3 7/'. ,/...... . .f�nfcc� wiring in the building of.... .........'`� 614eD.......................................... at .....7.r.'5 ............ KIC,,re- L........ �>27 '.. ; North Andover, Mass. `/fes{ ,f/} ECTRICAL INSPECTOR Check# �UsparGessetl o�,,tir,e Jewiet� BOARD OF FIRE PREVENTION REGULATIONS official use only Permit No,� Occupancy and Fee Checked Rev. 1/071 leave blank =Print form APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code {MHC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. ,J% 6 4) Bn& U r 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) � ( � G� rnS6n 4 Owner or Tenant �i fY) a a( I Cj ca Telephone No. 1p Q'3 ,3 & j— Owner's Address Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building w/ Solar - PV Utility Authorization No. n/a Existing Service Amps I 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: Install Solar Electric: - Photovoltaic (PV) system ( panels] ratedq, (p'LkW-DC S.T.C. Grid Tied. In conjunction with a Building Permit. r nm"llMlnn Attho rAll"I.4110 tall" "I". h., va,;.,.,.l h., A. f..e......a,...f eV..-na No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans o. of' oral Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ n» ❑ rnd. rud. o. o Emergency ng Battery Units No. of Receptacle Outlets No. of Oil burners FIRE ALARMS No. of Zones No. of Switches No, of Gas Burners o. bDetection an Devices No. of Ranges No. of Air Cond. Total Tons "Initiating No. of Alerting Devices No. of Waste Disposers eat Pump Totals: Number I Tons I KW I NT of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW I.atal' ❑ Municipal Connection 0 Other No. of Dryers Heating Appliances KW SecuritySystems: No. of Devices or Equivalent No. n Witter KW Heaters o. o o. o Si s Ballasts Data Wiring: No. of Devices or E ulrvalent No. Hydromassage Bathtubs No. of Motors Total HP a ecommunacatrons rip No. of Devices or Equivalent OTHER: Attach additional detail ifdesired. or as reyuirrd by the Inspector of'Wires. Estimated Value of Electrical Work: �7t OC) O ( When required by municipal policy.) Work to Start: A.S.A.P. 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 ❑✓ BOND ❑ OTHER. ❑ (Specify:) I certify, under the pains and peuaitles of perjury, that the Information on this applkadon it true and complete. FIRM NAME: SOLARCITY CORPORATION LIC. NO.: 1136 MR [Acensee> Mafthe%v T. MarkhamfSi store r LI C. NO.: 1136 MR tkapplicable, enter "exempt " ire the heave nunther fine./ Sus. Tel. No.. 774-25"180 Address: 24 St. Martin Drive (Building 2 / Unit 11). Marlborough, MN 01752 Alt. Tel. No: 774-258-8505 *Per M.G.L. c. 147, s. 57-G1, security work requires Department of Public Safety "5" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee docs not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one _El owner Q owner's a int. Owner/Agent Signature Telephone No. PERMIT FEE: $ " 0111ce of Consumer Affair% & BaRium Regatution )4,OME IMPROVEMENT CONTRACTOR Registration: 168572 Type Explraftrr 318120171, Supplement SOi_ARCiTY CORPORATION MATTHEW MARKHAM 24 ST MARTIN STREET BLD ZUNI SOROUGH, MA 01752 Undersecretary :0M k 4LTH Of VX 5 P rt ' �..iriiieYs L ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS Ax REGISTERED MASTER ELECTRICIAN SOLARCITY CORPORATION MATTHEW T nAR HA14 '.A 24 'SAINT MAR`T'IN ITR BLDG 2 UNIT I1 MARLBOROUGH MIA 01752-3060 1 ft a 31Ll 6, d " 0111ce of Consumer Affair% & BaRium Regatution )4,OME IMPROVEMENT CONTRACTOR Registration: 168572 Type Explraftrr 318120171, Supplement SOi_ARCiTY CORPORATION MATTHEW MARKHAM 24 ST MARTIN STREET BLD ZUNI SOROUGH, MA 01752 Undersecretary :0M k 4LTH Of VX 5 P rt ' �..iriiieYs L ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS Ax REGISTERED MASTER ELECTRICIAN SOLARCITY CORPORATION MATTHEW T nAR HA14 '.A 24 'SAINT MAR`T'IN ITR BLDG 2 UNIT I1 MARLBOROUGH MIA 01752-3060 1 ft a 31Ll 6, Address: 3055 CLEARVIEW WAY City/State/Gip: 01'UV tvim t r -U, uh vq-tVe mane if: --l --- The Commonwealth of Massachusetts Type of project (required): Department of Industrial Accidents '.j Dice of Investigations employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- I Congress Street, Suite 100 7. ❑ Remodeling Boston, MA 02114--2017 These sub -contractors have www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive (Business/Organizationtindividuai): SOLARCITY CORP Address: 3055 CLEARVIEW WAY City/State/Gip: 01'UV tvim t r -U, uh vq-tVe mane if: --l --- Are you an employer? Check the appropriate box: Type of project (required): I.0 1 am a employer with 5000 4. [] I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑ Demolition working for mein any capacity. employees and have workers' 9 ❑ Building addition [No workers' camp. insurance comp, insurance.t 5.0 We are a corporation and its 10.[-] Electrical repairs or additions required.] 3. R I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' camp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no SOLAR / PV 13.❑ Other__ employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fiat 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors 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 enrplayees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL INSURANCE COMPANY Policy # or Self -ins. Lic. 4: WA7-66D-066265-024 Expiration Date: 09/01/2015 Job Site Address: S� GchSan City/State/Zip:�C�'t 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 I3IA for insurance coverage verification. / do hereby cerito under the rains and pe►ialtles of perjtary that the b -i rnration provided above 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 5. Plumbing Inspector 6. Other Contact Person: Phone #: 16 A� V CERTIFICATE 4F LIABILITY INSURANCE DATE (MMIDDIY �' CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 081'P TOA THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, 'HIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT MARSH RISK & INSURANCE SERVICES PHONE ._ ............. ,.__._...,__... _..... .._...__. _....... ..... FAXA 345 CALIFORNIA STREET, SUITE 1300 -(A&-N% EaIU;.................. __---.—.___....... ..._.._..._..._......__....-_......._........i_(A+e _Nol—..._......_........_._.___ CALIFORNIA LICENSE NO. 0437153 E-MAIL ADRES,S SAN FRANCISCO, CA 94104 __._ .._..............._.__...._-----_.....,......__-__....._._._._.—__...... PERSONAL B ADV INJURY _..,__..----._.___._..... INSURERI AFFORDING COVERAGE NAIC,0 998301-STND-GAWUE-14.15 INSURER A : Liberty Mutual Fire Insurance Company 16586 —............_......_..._._..—_......_......,,..,_.,._......_.._._......_._._.._.....__ INSUREo — -- -- - INSURERS: Liberty Insurance Corporation 42404 Ph (650) 963.5100 _._ — r--.._..._._..-----__._._...._._...,_...............---...._.._.........}........_._...._. .- SolarCity Corporation INSURER C: NIA _......._...j--._.. _ _ ...... ... ... ......................... __.__..._w ......... _._.......... NIA _. 3055 Clearview Way INSURER D : AS2.661-066265-044 San Mateo, CA 94402 _ _..._._......_..------ ----- ---- _..__-_._..........--------...... ___... — 10000i! _4_._.... .... INSURER E: X ANY AUTO INSURER F: COVERAGES CERTIFICATE NUMBER: SEA -002440269.02 REVISION NUMBER:4 THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ —_ MR ___.........._._._._. ADDL UBk _. __.._.__..---....-----.....—....v. POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MW/DDIYYY MWDDIYYYY ....._._........._..-._..__.... �......... _......._......__... --- - LIMITS A GENERAL LIABILITY TB2-661-066265-014 091010014 09/0112015 EACH OCCURRENCE $ 1,000,000 X DAMAGE 1`0 RENTEII 100,000 COMMERCIAL GENERAL LIABILITY -- PREMISES„(Ea occurrences ..... CLAIMS -MADE OCCUR MED EXP (Any one person) S..__ 10,000 _._ PERSONAL B ADV INJURY _..,__..----._.___._..... $ 1,000,000 ......_..._.. _ ------- GENERAL. AGGREGATE _ $ 2,000,000 ._._...... _..._........_.... ...__...._........._ _.._.. GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY X PRO• LOC Deductible $ 25,000 A AU MOBILE LIABILITY _.. AS2.661-066265-044 0910112014 09/0112015 COMBINED SINGLE LIMIT _tEa accident _-- __. 10000i! _4_._.... .... X ANY AUTO BODILY INJURY (Per person) .........._ _.............- $ _._ ALL OWNED SCHEDULED — BODILY INJURY (Per accident) ..-._........__.. $ AUTOS _ AUTOS — _ X X NON -OWNED PE20PERTY DAMAGk $ HIRED AUTOS AUTOS ANEaccidesltj, _ __ .... X Phys. Damage COMPICOLL DED: $ $1,0001$1,000 UMBRELLA LIAB i OCCUR EACH OCCURRENCE $ - EXCESS LIAe CLAIMS•MADE GREGATE AG. $ DED RETENTION $ $ B WA7-66D-066265-024 0910112014 09/0112015 X WC STATU OTH 8 YIN AND EMPLOYERS•PART Wr,7.661-066265-034 (Wq 09/01/2014 09101/2015 TORY.LIMITS ER ........ _ 1,000,000 ER ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � N 1 A -E L EACH ACCIDENT $ B (Mandatory In NH) WC DEDUCTIBLE: 5350,000` E.L. DISEASE. • EA EMPLOYEE $ 1,000,000 If yes, describe under _._._.._..__....._.....__. ..._...._ . __..._..._ ._._... .----._...__.... _ -- 1,001.000 DESCRIPTION OF OPERATIONS below E L. DISEASE . POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (Attaoh ACORO 10i, Additional Remarks Schedule, if more space Is required) Evidence of Insurance. f CERTIFICATE HOLDER CANCELLATION SolarCity Corporation 3055ClealviewWay SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN San Mateo, CA 94402 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh Risk & Insurance Services Charles Marmolejo C s-- ©1988.2010 ACORD CORPORATION. All rights reserved. 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C 'rr .�. ' L, `J p N Q U a U S � ° L � �. a � J= W X F: mx vc � nUc a ®mow 3 Q h o �a C .. �� o. �..'y a 3 4to3 col -Oa <0Q.U.:�-aa0a�1oQ0� n0n-0 � t ��� North Andover Board of Assessors Public Access Page 1 of 1 NOR7M Forth Andover Board of Assessors Zroperty Record Card Parcel ID :210/107.A-0027-0000.0 FY:2012 Community: North Andover Click on Sketch to J Location: 815 JOHNSON STREET Owner Name: APPLETON, WILLIAM B. APPLETON, SHERYL J. Owner Address: 815 JOHNSON STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 7 - 7 Land Area: 3.52 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3696 sqft . E A 11 ZffMj8ff1jjjMj. Total Value: 522,300 522,300 Building Value: 277,500 277,500 nd Value: 244,800 244,800 rMarket Land Value: 244,800 (Chapter Land Value: Sale Price: 1.00 Sale 03/22/2006 Date: Arms Length Sale F-NO-CONVNIENT Grantor: APPLETON, Code: WILLIAM Cert Doc: Book: 10089 Page: 285 http://csc-ma.us/PROPAPP/display.do?linkld=1896018&town=NandoverPubAcc 6/8/2012 IV 14 0o ti N O O O O x lz 2 N o aj J L�6 a) la) m pQ 62W fn N yN C Qca CL ) 00)) c " o — 0 a (1) 2260 c O N O 5V } Ha2 LL W ao W �' c H m ) 0) (D cc Z 0 -01=�m O U) z x 0 c 0 Ln 000 O r N r ° g 0 cw occur co IL 8 Q z Of W o W N J nQ Q 0 a a O 4. -OaLL a Oaio 2 (6 U ai -Q.= O` t= O 0. 0 !— > O -Op OO N 0) _N 0) cc 76 76 OS 70 U) (n (0 co 0 ti N cm LO O H M M 0 Y co O aiiri�Q to 0 coo a OUiio a y m o 0 0 0 d Q O Z o0 CD O p —L J m U) 7 v O Go Q ti Z Q} LLJrL O J J W H W W J fn o U �w ZO of a 00 =Z Q W JJ vin U Baa cl) CL 0. 2LOO Q3QQ-Doz CL I 10 Q 4- 0 L6 CL 00 N 0000 NIli U V7 N N m U (0) tt M c c O 7Lo1-1 0 r o UNN Y Y .1L i r > N Z O O - W 00 aoo 'p Z N N 3 00LL 0a/ �M Z a°LOOL0 W �z dOM �o t`�oLNn c0�aa Zoo QrN — 3 LL U LOQ Z L` r-: i ?(� wOO �QQ O NNill� USE p LL to rn- a. 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U U) iii O mut N aqp Li e iii LL OE w j t LB t6 co0 Co N � al)0�00 w w 7 O O m L0 NOC?w Uo ` lf)!J9 IfIS!)kc CO Co Lr � 0 in � .c Y — =L) i k Lf) HMLLMwoc mYw mmQ "� m CO N 14 Ln Ln m V U04 LL N U)0 z rn Ho aid U = H0 OL >, 0 0 m o (1) = Y i4U)ww2LL 2LLLLU WCLI cA 4- 0 L6 CL North Andover Board of Assessors Public Access Page 1 of 2 http://csc-ma.us/PROPAPP/newSearch.do?noOwner--027%3B084%3B059%3B004%3B 13... 6/8/2012 North Andover Board of Assessors Public Access Page 2 of 2 2012 210/107.A-0090-0000.0 920JOHNSON STREET ALBERTA REALTY TRUST ALBERTA C. MCMAINS,TRUSTEE 2012 '210/107.C-0042-0000.0 927 'JOHNSON STREET 939 JOHNSON STREET SIROIS, WILLIAM G, ELLEN A SIROIS PHANEUF, CHRISTOPHER D, DONNA L PHANEUF 2012 210/107.A-0172-0000.0 2012 210/107.A-0091-0000.0940 JOHNSON STREET TAYLOR FAMILY TRUST, C/O ABBY T. DIAMOND 2012 210/107.A-0008-0000.0 950 JOHNSON STREET BLANDINI FAMILY TRUST, VINCENT & CYNTHIA BLANDINI, TRUS 2012 -210/107.A-0171-0000.0 953 JOHNSON STREET SCHNAKE, LESLIE M, - CARRINGTON MORTGAGE SERVICES, 2012 210/107.A-0007-0000.0 960 JOHNSON STREET LLC, WELLS FARGO BANK N.A., 967 JOHNSON STREET TRUSTEE PACHECO, JAMES A, PACHECO, MAUREEN 2012 210/107.A-0221-0000.0 2012 210/107.A-0098-0000.0 970 JOHNSON STREET COSTELLO, MYLES J, JR, CAROL A COSTELLO 2012 210/107.A-0222-0000.0 _ 981 JOHNSON STREET WESTPHAL, MARTHA A., WESTPHAL, GARY DUSSAULT, DANIEL & NANCY, 2012 1210/107.A-0030-0000.0 990 JOHNSON STREET 2012 210/107.A-0226-0000.0 991 JOHNSON STREET MANNING, MAUREEN B., 2012210/107.A-0136-0000.0 1000 JOHNSON STREET FRAGALA, ANTHONY R, NELLIE M FRAGALA 2012 210/107.A-0158-0000.0 _ i 1001 JOHNSON STREETTMANSOUR, ROBERT L, MARY M _ _ 2012 210/107.A-0137-0000.0 201210/107.A-0154-0000.0 _ 1010 1015 JOHNSON STREET JOHNSON STREET (MANSOUR COOKSON, ROBERT W, C/O TEN TEN JOHNSON STREET REALTY TRUST LIGHTBURN, THOMAS E, LIGHTBURN, DIANE G 2012- 210/]07.A-0155-0000.0 1029 .JOHNSON STREET FEDERICO, MARK ALFRED, KRISTEN M FEDERICO (__1210/107.A 2012 210/]07.A-0065-0000.0 1030 + !JOHNSON STREET LUZ, ADRIAN, LUZ JENNIFER B. E2012 210/107.A-0150-0000.0 1041 JOHNSON STREET BROCKBANK, JEANETTE M, i 2012 210/107.A-0035-0000.0 1044 (JOHNSON STREET LOMBARDO DAVID W, JEANNE M - -i_._-_ � -- - - - - _ . - -- - ---I --- - -- - - 154 items found, displaying 101 to 150. First/Prev 1 1 2 1 3 1 4 Next/Last http://csc-ma.us/PROPAPP/newSearch.do?noOwner--027%3BO84%3BO59%3BO04%3B 13... 6/8/2012 JOHNSON ED HORIZONTALLY 'HOWN ON THIS CEMENTS OF NMENTAL CODE. STREET 815 JOHNSON STREET, NORTH ANDOVER Date.. -'/ ..... r 0" HORTF, TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION • a This certifies that ... 3 A �j ..r-llv - --e ............ has permission for gas installation ..... V V. 73 .................. in the buildings 1of .. 1. �. ,1c .............. • • .. • ....... • • • at ... Sri. � .. J.���,.,� f..... ..C,':...... ,q, North Andover, Mass. Fee. 30.' . Lic. No. 7 Y2.*-. . ' �?-- COR ' � . , I * I * . GAS INSPECTOR Check # 136-9v 5692 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT Ta (Print or Type) 00ffh ANDOVE2 —.Mass. Date G ty DO GASFITTING Permit # �T 9 L Building Location ?15 JOHMS01� S I Owner's Name GOJ LLI AM A pP-d NORTH /\, N 00VC 2 r tl A Type of Occupancy_ iS 1 Nr_ lJ`f 1 A L New ❑ Renovation ❑ Replacement] Plans Submitted: Yes❑ No [] Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone q 7 b- 6 8,7-'l 10 5 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: X ] Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: have acu renntt liability insoura❑nce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy P( Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mplianoe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (j "y- Plumber Y T e of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter City/Town Master License Number _374"5 APPR OVED O FICE SF ONLY Journeyman MENSWMI Sol . .. ■������������r«nENNEEMENNOM s���rf���a NEENNE own ON mm"WEENNNEMENEENNINEEN so 0. NE �r�■ son MEN mono Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone q 7 b- 6 8,7-'l 10 5 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: X ] Corporation ❑ Partnership ❑ Firm/Co. Certificate # 1862 INSURANCE COVERAGE: have acu renntt liability insoura❑nce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy P( Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in abo pplication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mplianoe with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (j "y- Plumber Y T e of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter City/Town Master License Number _374"5 APPR OVED O FICE SF ONLY Journeyman Y- J 2 O W N a w. U LL LL O a O W 3 J W m n z� H 1-' I LL N 3 d O O O t - F' • a o w Z a a O LL z 0 F" a v J IL a a ur w LL P U W 0. :fit .. _'�•� N Z JI Q Z LL CL N N w a O O a a ur W LL X (Nii i V 0 Z F- F - LL N S t7 O A O F- o a w z a O LL Z 0 Q V J CL CL. a a n O a w to J a O z d J �\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TC (Print or Type) -j )Q? -T -H, AN DDU6P-- • Mass. Date 0P / 06 6 C!� DO GA.SFITTING Permit # 61 9 L, 3t) Building Location _ ?IS JCM SSDi� ST Owner's Name Gil LLI AM A PPL _ i 6 N NORiH 1\1`1300VER-tilA Type of Occupancy RE,SI nF UTIAL New ❑ Renovation ❑ Replacement�j Plans Submitted: Yes❑ No ❑ Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET RC1 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone_ 9 7 !B-6 8,7-'l 10 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have acu rent liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes nto If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy P< Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ BYT e of License: Plumber Signature of Licensed Plumber or Gas dZaCj Title Gasfitter Master License Number 374-5 City/Town Journeyman APPROVED 0 FIC SF ONLY • ... ■ORNMENNEORN«N IRS MIS on ENO■ son so • pro■ son Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET RC1 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone_ 9 7 !B-6 8,7-'l 10 5 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have acu rent liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes nto If you have checked res, please Indicate the type coverage by checking the appropriate box. A liability insurance policy P< Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent El I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ BYT e of License: Plumber Signature of Licensed Plumber or Gas dZaCj Title Gasfitter Master License Number 374-5 City/Town Journeyman APPROVED 0 FIC SF ONLY Location No. 13dl Date ca TOWN OF NORTH ANDOVER n ~ + Certificate of Occupancy $ '— sr Building/Frame Permit Fee $ JACHUSE Foundation Permit Fee $ _ Other Permit Fee $ .� Sewer Connection Fee $ `— Water Connection Fee $ d, . TOTAL $/_ %a� Building Inspector Div. Public Works PI M I XI n W :n Y U 9 0 F3 V Z .f•:� W W W N T z d f c; i � Lam. i f i j v iy a Y y v� - n N Yi UJ v a z C C u @3 5 �• a .Z L Z Iz L Z L y ,l z h to z w i � n W :n Y U 9 0 F3 V Z .f•:� W W W N T 0 z d f c; i � Lam. i f i j v iy cp y LLI u v C) v 7 O z C C u @3 5 w t J ,l z h z w i � z LLI C L W _ i o LLI p cZ w ¢ toy L Y = J w J C Z " Lc, Z z �` z �5 0 z - L L C CL a in z a Ar 0 z d f c; i � Lam. i f i j v iy cp y LLJ z z z a u @3 0 z c; i zo sn M — Jc An cp y LLJ z z z a 2.r MUM z_ z z, _ F=ORM U - LOT 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 or requirements. --_----*�********v*'-***'**-**APPLICANT FILLS OUT THIS SECTION* PHONE APPLICANT I,. LOCATION; Assessor��s Map Number PARCEL SUBDIVISION LOT (S) STREET QJ) 5a�+^S � 5� ST, NUMBER6/J' r.-..*�-�- *-►--*•*-*************'OFFICIAL USE ONLY***,r*.***,,,.... " RECO J __�v CONSERVATION ADMINISTRATOR MENDATIONS OF TOWN AGENTS; COMMENTS DATE APPROVED DATE REJECTED DATE REJECTED COMMENTS APPROVED FOOD INSPECTOR -HEALTH DATE ATED A DATE REJEC SEPTIC INSPECTOR HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT;�Cc; RECEIVED BY BUILDING INSPECTOR DATE Registry of Deeds Northern District of Essex County Lawrence, MA 01840 . 03/18/99 APPLETON # 164 Rec: jr.•,a irk. # 165 Rec: Total # 166 Payment Check JC Type PLAN 16.00 Copies 1.50 Type CERT 10.00 Postarae THANK YOU! Thomas J. Burke Resister of Deeds V. HOR71, �YCE Ei?A,,Sra�4 TOWN OLS ;K NORTH A11GOVcR 1II TOWN OF NORTH A N.,. -b /LR MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Property: 815 Johnson St. on I DATE: 11/12/98 Ht:I I I JUN: U41-98 HEARINGS: 10/13/98, & 11/10/98 0.33 ' meeting on Tuesday evening, November 10, 1998, upon the application of )hnson St., North Andover, MA. requesting a Variance from the requirements 2, within the R-2 Zoning District, for relief of front setback, and for a Variance 27.83 paragraph 9.2 (3), relative to an increase in area of non -conforming use more a Special Permit from the requirements of Section 4.121 of paragraph 17 to 27.83 g carriage house. t: William J. Sullivan, Walter F. Soule, Raymond Vivenzio, Scott Karpinski, awrence Tribune on 9/29/98 & 10/6/98 and all abutters were notified by regular Soule, and seconded by Raymond Vivenzio, the Board voted to GRANT a 1 9, paragraph 9.2 (3) for relief of an increase in area of non -conforming use of or the original use of the existing dwelling of 3126 sq. ft., and to GRANT a is of Section 4.121, paragraph 17, to construct a family suite (with restrictions carriage house, and that the family suite will not be more detrimental to the - = ivan, Walter F. Soule Raymond Vivenzio, Scott Karpinski, George Earley. ivenzio and seconded by Walter F. Soule, the Board voted to GRANT a i Section 7, paragraph 7.3 for relief of front setback of .9 feet (9 tenth of a foot) carriage house on a pre-existing structure on a non -conforming lot. Voting in Soule, Raymond Vivenzio, Scott Karpinski and George Earley. cion of Section 10, paragraph 10.4 of the Zoning Bylaw and that the granting of ect the neighborhood or derogate from the intent and purpose of the Zoning nd/or Special Permit as requested by the applicant does not necessarily nit as the applicant must abide by all applicable local, state and federal and —vul'u, y �kduv, d„V ,uyu,duUrra, N„Urto the issuance of a building permit as requested by the Building Commission. BOARD CF APPEALS William J. SUIlivan, Chairman deCcCU2 Zoning Scar j of appeals F6j cz 00 xO w Q x O� m v �u u o U. E N a cn z Ou z z G CIS w° v U ie w a O u a to 7 w a w u v ►-� W c�° cn is w W z d m m w w w x kr v C z ,. o -Y p c r- o D c c 2 Ic,� "' o Sv 0 .� cm 401s 2f / o �- Lin ?� J \� AAl1 �oM o n� UCr ei COM.s 4 E y R i... m 2's z`4. y Cc, ts; 3 c c y O O :ESNC* 'D CD o CD �: •�' L c c :roc c y � O yac� L� 3: mom wyo C., LO) o w oac cm S Q m m e c = m a =(D N �uiLA •CL � ea C Z W E cS •w v •vi O V m O m C COD CL m > y 0:6 _ ca m So•� O i1 I r'1 ti CDy .E CLL CLQ c 0 co C., _m r. y O .V CLW O V O O J ni `C o S i vl v J J -�, r �, cs q 0 o CX Cl L O J ni `C o S i .6 323- Date.. (F- Z.-.19.••••• A TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATIONS A / f .�• This certifies that ... ............... has permission for gas installation,.:.' .:........... -� -�.!: :° in the buildings of .. ......':.. .................. o at'..........North Andover, Mass. Fee : � Lic. No........... ? ........� .....:.:..:;�. GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4& Fri `017 So, Q 0 0dj -�' 7' s d 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 5-1150 (Print or Type) ILN Mass. City, Tow Building o AT: Location O �.� �D I"1 Y1 SOGI S New P Renovation ❑ Plans Submitted Yes ❑ No Z Date —?—/0 19� Permit #� cS Owner's Name Ul b Fo�jy 4� Type of Occupancy. Replacement ❑ (Print or Type) _ Check One: Certificate Installing Company Name I 15 Plum 121 nd! -1—P) P I n 9 co Address C-7 7-f s�ivT ❑ Corp. ❑ Partnership ( Firm/ Company Business Telephone i �o./ S3 L���O Name of Licensed Plumber or Gasfitter %tfom/9-s Lot- ea12774� 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. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. ❑ By Title City/ Town APPROVED (OFFICE USE ONLY) , FORM 1243 MOBBs A WARREN, INC. 1W9 TYPE LICENSE: Plumber ❑ Gasfitter ,I Master ❑ Journeyman J t &(mrt- Signatur of Licensed Plumbjer or Gasfittn�er mb (3? License Number i (Print or Type) _ Check One: Certificate Installing Company Name I 15 Plum 121 nd! -1—P) P I n 9 co Address C-7 7-f s�ivT ❑ Corp. ❑ Partnership ( Firm/ Company Business Telephone i �o./ S3 L���O Name of Licensed Plumber or Gasfitter %tfom/9-s Lot- ea12774� 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. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/ Agent I have a current liability insurance policy to include completed operations coverage. ❑ By Title City/ Town APPROVED (OFFICE USE ONLY) , FORM 1243 MOBBs A WARREN, INC. 1W9 TYPE LICENSE: Plumber ❑ Gasfitter ,I Master ❑ Journeyman J t &(mrt- Signatur of Licensed Plumbjer or Gasfittn�er mb (3? License Number v a m R-1 z O N m A Z m N T w O O m N N z N 'O m A O z W m r O 3e O m O In m e N m O z r w J z O W N W V r6 LL. O oc O W 3 O .j W m Y z O P W d N z r N N W cc 0 O oc IL, z O h V W d N z 1 Q z m W W LL O z C W F z Q 0 r oc W d Ci W H D iaquxnN asumi-I (Z95600 w ial;gs g io iaqumid pasuoagjo lnl>;uBiS 44m 7 uEwAawnop ❑ 1ai3gs�� ❑ iagcunid :3SN33I'I 3dAl 696L'0Nj'N3UWVMV SBBOH COU M0.4 ' WiNO asn aoimo) a3AOdddb unnoZ /,C�►� atii.L �g asgmon suopgjado palaldmon apnlnui of 6n.1 anug�nsu. SI�i�ggy lumina g aneq I Juavv /iaumo Jo amira!s •asgjanoa suonviodo palaldwoa Suipnlau► aougansut Alg!gvq aneq lou op 11941 luaSE sty io iauMo aql paw1o;m aneq I •SA%Vl 18tau0o aq1;o Z171 jaldgyj pug opoo sug almS snasnyngssuN aqi;o suoistnoid luauillad ilu ql!m anuggdwoa ut aq piM uonemiddg sigl io; panssi 1►wiad lapun pawaopad suot)vIlvisui pug lioM Su►gwnjd lig lgyl pug aspalMoul dw;o isaq aql of alginang pug anil air uollgagddg anogg w (paialua jo) pail►wgns aneq I uollgwio;u! pug sjiglap aqi Jo [[g iggl 6,Iivao Agalaq I aimplaD U .laligsug .lo iagwnid pasuaot-I 3o aul>7N Auudwo3/u1.n3 digs.lauligd ❑ •d.loD ❑ :au0 Noa4D 5 auolgaaia j ssauisng -YV,-(1S-YD0 Ji L ssa.1PPV at au rN Autdwo:) guttivisul (adAjL so 1upd) ❑ juawaoeldaa a �(oul?dnoop )o ad�(1 11��4Y0 0aweN WIM/s,JeuMp # 1!wa8d 61 O � � ale(] ON ❑ seA paulwgnS suald uolIanouad D� MaN —� sr uol1eoo� Bu!PI!n8 f MOl `40 .SSLW - a"dm 1 [/�� � N :lb ,w 9 o" (ad�(1 ao luud) JNlllldSVD Oa Ol llWd3d MOd N0llV3llddd WH0AlNn Sll3snHOdSSdW �O Q 0 0�' o% IIIIIIII�III�IIIIIIII���I�I ❑ juawaoeldaa a �(oul?dnoop )o ad�(1 11��4Y0 0aweN WIM/s,JeuMp # 1!wa8d 61 O � � ale(] ON ❑ seA paulwgnS suald uolIanouad D� MaN —� sr uol1eoo� Bu!PI!n8 f MOl `40 .SSLW - a"dm 1 [/�� � N :lb ,w 9 o" (ad�(1 ao luud) JNlllldSVD Oa Ol llWd3d MOd N0llV3llddd WH0AlNn Sll3snHOdSSdW �O Q 0 0�' o% i2 4112 i Ir This certifies that .... ..... ..'................. . has permission to perform"..:.-- plu rVd):ihg, in the buildings of ..- ................ . at' '. ". I ...-.. v�!V ..... ,North Andover, Mass. Fee �?. '�.. Lic. No d/�9�� J. ,T, .......... .'"' ' �` I PLUMBING INSPECTOel 1 L Date.. �. ..!. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING WHITE: Otilllbf7� 14:&INIII: Bt�l.c%g DMD PINK: Treasurer `cF7 50, 0 0 d 9 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) 1?— / 0 Mass. Oate V — / 19 Permit # 7 1/ 2— 7 Z' F Nr Building Location Sly Tohnson cJ I Owner's Name Iyit M&M Y/ Pe�QA /)/, ��/Doye-p- T Occupancy—k y New Renovation ❑ Replacement ❑ Ragi tted; Yes ❑ No FIXTURES Name of Licensed Plumber Check one: Certificate ❑ Corporation ❑ Partnership _ 3 7 - l J Firm/Co. _ 7't�om�ts c� 0 Q f~Lem INSURANCE COVERAGE: have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 7, No 7 If you have checked yn, please indicate the type coverage by checking the appropriate box. A IlabllRy Insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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: Owner C 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 perlorme nder the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbin Code d Chapter142 of a Gener Laws BY Signalure o Licensedum er Title City/Town Type of License Master 5-41—� Journeyman CD APPO'V( PPfiE License Number 1 S 9t _ in < VI N0 = 0 Y zW H VI r W N Y J J VI Y <r U < v1 O 10 lA G ¢ n _ V7 < ¢ ¢ z ¢ N = z _ F O U Q m N S H Y U < W r' 0�[ o z C a < ut ¢ tl O ¢ ; X ¢ z yJ O< r- 7 ►- �+ < ; W 0 O C Z{ 3 J VI O ¢ ¢ F J < 19 Y O C O W S W = U < s 2 Y- O =CL z = Y z 4 O p p ur __ = W W ►- o �u r. Adcr SUB—BSMT. BASEMENT IST FLOOR t 2NO FLOOR rr f 3R0 FLOOR 4TN FLOOR STM FLOOR 6TMFLOOR 911 7TH FLOOR aTN FLOOR 1 Name of Licensed Plumber Check one: Certificate ❑ Corporation ❑ Partnership _ 3 7 - l J Firm/Co. _ 7't�om�ts c� 0 Q f~Lem INSURANCE COVERAGE: have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 7, No 7 If you have checked yn, please indicate the type coverage by checking the appropriate box. A IlabllRy Insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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: Owner C 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 perlorme nder the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbin Code d Chapter142 of a Gener Laws BY Signalure o Licensedum er Title City/Town Type of License Master 5-41—� Journeyman CD APPO'V( PPfiE License Number 1 S 9t v s T z 0 I" m T z Pp r i N v T a 0 z N Y J z O W N W u L6 LL O a 0 LL 3 O J W m u N LL 0 Z O J_ m LL O z OP u O J A a O r u W A N Z v m i J s ,agwnN 0su0311 AINO 3Sn DId30103KO M/ Jo ❑ uevuawnor kjalseV4 asuaoil to ads( j alul ja wn Id POSUG311o em eu6i 1t13 unsl fjo Zql J9)de4: p spo'J 15uiqwnid 9ls1S spesnyoessey4 ey1 to SuolslAold lusuilied Ilt 4pM aouegdwoo ui eq Ip* uogeogdde siyl sol ponssi pwied 941 jepu aw,oyad suoilv11alsut put 4ioM 6u+gwnld Ile 1x41 pus a6polMouil •Sw to lsaq e41 of ale Moot put en,l eje uogeogdde anoge ui (pa,alus ,o) polltwgns ant4 I uo lewJolw put s11919p 941 io Ile Ryl App o Rga,a4 I ❑ ►uaBd [NuMQ :Quo Moa40 luawailnbaj siyl sanleM uopeolldde 11wlad sp43 uo ainleuBls Aw ley► put smeq lejaua0 'ssepN a43 10 Zbi jalde40 dq pannbaj a89J9no3 aouejnsul ayl Aso aasuaoll a43 1941 a19Me well I 1:13AMM 30NVunSN1 SA13NMO ❑ puof3 ❑ Alluwapul )o adAl ja430 ❑ Ao►pod oomnsul A3lllghl V xoq aleudoadde a4► Bul11oago Aq 080JQAoo adq a41 alsolpul ossald TUpo13oa4o an94 not 11 J ON saA Zbl 40 1JW to sluawailnbai a41 slaaw 4o!gm ►u21tnlnba Iel►ue►sgns sy jo Aollod aou9msul AllAgell nno a 2ns4 I :30V!l3A00 30NvdnSN1 aO'VVjogwnld Posu8311 0 oweN alto!1!pa0 dlysjauued ❑ u011ejodio0 CJ :auo Noa40 mmmomommommmmmoommomm t■t■����■fit■■■����■t ■��N�� ��■nen■�����■�����■■aa■��� ............e.... .....gym ON ❑saA :Pall.j� a s� �touedn�op S3dnlxli ❑ luawoospdad ❑ uolisnouapd MON Is I Vo a1 {�( t! �aw9N ZdauMO S f Q uolleool Bulplln8 i !t 3!wjad 8l DIV(] sseW ' a if eT� V (ad.cl ,o loud) Mawn'ld oa Ol llWd3d dOj N011d01-1dd`d WdOdiNn S113SnH3VSSdW �d Qo +os 40/ A ,A K f Location No. Date TOWN OF NORTH ANDOVER so 9 Certificate of Occupancy $ Building/Frame Permit Fee $ s�cNus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # r u. ,,/ Building In ector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI'RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING nAn^> BUILDING PERMIT NUMBER:DATE ISSUED: 455-�- 1 . P P �d SIGNATURE: Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: S i S -a-0 tiA 5K3 n S;-,- /0 `% Iq D o Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning DiAiic­t Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide RegWred Provided R 'red Provided 1 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2- PROPERTY OWNERSHIP/AUTHORIMDAGENT rill oriCDistrict: Yes No X �! I Owner of Record /a1erojkn SUn Si" Acme (Print) Address for Service 1&4-9'IFs L£SZ- 313-1 S gnature Telephone 2.2 Owner of Record: Name Print Address for Service: i nature Telephone SECTION 3 - CONSTRUCTION SERVICES s .l Licensed Construction Supervisor: Not Applicable ❑ e-Q AV) F Fro, n cz c-o ev, Licensed Construction Supervisor: ®142- LA 3 LA License Number z �— i\ 1 (;� d } Address ¢R� Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ HANCOCK BUILDING ASSOCIATES, ING, S CompanyNad,48 millOS dg. 2�O\ Chelmsford, MA 01824-4126 Registration Number Address Q.I, 2 &L ^ 2.120 Expiration Date Signature Telephone T M X Z O O z M 90 O Mn r r r s z G) 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 ...... X No ....... ❑ SECTION 5 Description of Proposed Work check all a licable New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) K Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 5M19 C )C 'sVk ` 'd -Y kodr4 a S��,� � _ art scra�l T-tQ'Wc Rr'tl° o.n� kSfYtc� int( SSC i'Ji` SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier a S, 0d U 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 2'5. UW SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, \14 k�'kr AMN NpPke-ib,n , as Owner/Authorized Agent of subject property Hereby authorize (&J � Lc_k k n) M S U C• to act on all matters relative to work authorized by this building permit application. C8�� //- /-Si ature of Owner Date -Signature SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, LZe-gk-I co w' ' ,as Own /Authorized Agent f 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 V� ,2Q k f1 Print �Naame �( ,, g �t _�k- Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TAMERS 1ST2ND 3RD SPAN MIENSIONS OF SILLS DIMENSIONS OF POSTS DM ENSIONS 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 SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 6 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 ...... X No ....... 0 SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) K Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Si 2k,p C X "ST SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed bypermit applicant OI 'ICI I. 01, 1. Building (a) Building Permit Fee Multiplier a S.. Gd 0 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 2 5, UW SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, al e ' �A k AT-, , as Owner/Authorized Agent of subject property Hereby authorize O'A r► C CA( (&J t C�k_ k n) I y S b C,. to act on all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 1Z e_gk-1 ,as Own /Authorized Agent f 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 1.� P-tJ k n F'exx n co ev l� Print/� \ `�Naame /�' kto,k Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS 1 ST2ND 3RD SPAN DEViENSIONS OF SILLS DINIENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIVINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ' TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVAT& OR DEMOLISH A ONE OR TWO FAMILY DWELLING 4; . :;�. n i7DG BUILDING PERMIT NUMBER: DATE ISSUED: /. /j Lt4VALI SIGNATURE: Building Commissioneffl for of Buildings Date SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 5 —X0 Hn 5c3 /0 9 1-q Dov . Map Number 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 Required Provide Required Provided ReqWred Provided 1.7 Rater Supply M.GL.C.40. 54) 1.5. Flood Zone Information: Zone Outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT IS onDistrict: Yes NO K 1 Owner of Record %.%J o f \ t gy m. APO12T-0 n g (5 .-a kn Sw) Sr 14ame (Print) Address for Service q'7 Sr, GssZ_ 3131 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: lignature Telephone SECTION 3 - CONSTRUCTION SERVICES 7.1 Licensed Construction Supervisor: Not Applicable ❑ ® 1-t2 4 3 Licensed Construction Supervisor: License Number Address LA- 14 - 0(„ K t?/i" E-i-1L{/hC&y ` Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ HANCOCK BUILDING ASSOCIATES, INOm CompanyN 1l! Road, bldg. 2 Registration Number 4 -1ct -p fo Chelmsford, MA 01824-4126 Address _ W'U' f : ' fl.tyr„L4 � Q i SC • " Z7 2-% \ Expiration Date Signature Telephone Ma rn X Z O O z rn 90 O r v r r_ ^^Z Y) ` 91te �Commvnmvaa d Board of Building Regula ions and Standards One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration HANCOCK BUILDING ASSOCIATES, INC. Robert McCrensky 248 MILL RD. BLDG. 2 Chelmsford, MA 01824 Registration: 100158 Type: Private Corporation Expiration: 6/10/2006 Update Address and return card. Mark reason for change. [] Address 0 Renewal R Employment [] Lost Card t+G WOO BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 442434 Blrthda,te: 44/14/1164 Expires. 04/14/2006 Tr. no: 20615 Restricted: 40 KEVIN E FRANC05UR 3 YORK AVE CHELMSFORD, MA 41624 AEting C t isidonej OP IDK CERTIFICATE OF LIABILITY INSURANCE � 10 , I PRODUCER Enterprise Ius.Services,LLC The M^_C�thy Gompani_es 299 Zallardvale St Wilmington MA 01887 INSURED ChdHaneoclk Builcd�i�i.nqc� Adss aiates, lmma ordOMAU 011822 a COVERAGES _ HANCO- I 04 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 # _iNSURERA; peerless Insurance Compa�r INSURER B: AtlanticCharter INSURER C; INSURER DI THE POLICIES OF INSURANCE LISTED BELOW HAVE 36EN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANOINO ANY REQUIREMENT, TERM OR CCNDITIDN OF ANY CONT RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE !SSUED OR MAY PERTAIN, THE INSURANCE.AFFORDED BY THE POLICIES DESCRIBED HERdN 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. ANOPEGATE LIMITS SHOWN MAY HAVE BEEN REDUCED SY PAID CLAIMS. R D" LTR N LT TYPE ( INSURANCE �FECTI9E�POi]CS' EXPI POLICY NUMBER DA M DO DATE MMIDDIYY LIMITS A GENERALLN1iliLdTY EACHOCCURRENCE �T7aMAGE'TO R X I COMMERCIAL GENERAL LIABILITY CER9788545 10/22,/04 10/22/05 !FS (Es CLAIMS MADE ®OCCUR MED EXP (Any ono yerson) PERSONAL &ADV INJURY $1,0001000 x 1001000 $5,000 $ 1 000 '000 GENERAL AGGREGATE !s2,000,000 IS 2 000 1000 GEN'LAGGREGA.TELIMIT APPLIES PER' I PRODUCTS-COMPIOPAGG PDLICY JEC LCC A ^ AUTOMOBILE LIABILITY ANY AUTO COMEINED SINGLE LIMrr I (Esaccidenl) ^' 6 ALL GNTIEO AUTOS SCHEDU�EDAU70S 90OlLY INJURY I Terpvwn) S J HIRED AUTOS I NON -OWNED AUTOS I BODILY INJURY rov aeNdenq S PROPERTY DAMAGE (Per b0[ident) i 5 �GARAGE LIABILITY HANY AUTO i i AUTO ONLY • EA ACCIDENT $ s i EA ACC AUTO ONLY; AGG I $ EXGESSIUMBRELLALIA81LiTY — OCCUR CLAIMS MADE I I i &ACHOCCURRENCE AGGREGATE S $ – DEDUCTIBLE S I RETENTION 5 S WORKERS COMPENSATION AND B EMPLOYERIETO ILITY ANY PROPR�TOFGPARTNERlFJiECUTIVE OFFICERIM5MBER EXCLUDED? I If yes, describe under - SPECIAL PROValONS below WC 100,307302 I 02/01/04 ! 02/01/05 – TORY LIMITS ER { E.L. EACH ACCIDENT 1 S 500000 E.L. DISEASE - EAEMPLOYEE! S 500000 $ 500000 E.L. DISEASE -POLICY LIMIT! OTHER i I I DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICL< S I EXCLUSIONS ADDED BY ENCORSEMENT I SPECIAL PROVISIONS Carpentry -1-1 .--1 V i HANBUIL SNOULDANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE MMIRATIOI DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRIlYEm NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OUT FAILURE TO DO $0 SMALL 24488 Mill Rd Bldg #2>3HiBuilding Associates IMPOSE YOOBLIGATION ORLIABII,ITYOFANY KIND UPON THE INHTS SUREKITSAGEOR Hill Chelmsford MA 01821 REPRESENTATIVES, ACORD 25 (2001/08) TOTAL P.01 name: location: city vhone # ❑ I am a homeowner performing all work myself. ❑ Lam a sole proprietor anA-have no one working in anv capacity I am an employer providing workers' compensation for my employees working on this an :name. L J I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have Failure to secure coverage as required under Section 25A of Mk,L 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day 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 herebycertifyunder the pains and penalties of perjury that the information provided above is true and correct Signature � � Date _ 1, k <�- , 0 '-A Print name X e,, i r1 F— FTG /1 Lca e-cJ er. Phone # Q 7 �- - 2 S 6 official use only do not write in this area to be completed by city or town official city or town: ❑ checkifimmediate response is required contact person: (revised 9/95 PIA) permit/license # ❑Building Department ❑Licensing Board ❑Selectmen's Office ❑health Department phone #; ❑Other 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: 30 `I�c� l�� �sv� G' zr�ti�M wry -STC 61,C4 S"y ZkCc 14,JJ4 (Location of Facility) Signature of 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 CONTRACTING AGREEMENT Read this agreement and make sure you understand it before signing it. This agreement has legal force and effect and binds those who sign. NOTICE: All Home Improvement Contractors and Subcontractors engaged in home improvement contracting unless specifically exempt from registration by provisions of Chapter 142A of the General Laws, must be registered with the Commonwealth of Massachusetts. Inquiries about registration and status should be made to the Director, Home Improvement Contract Registration, One Ashburton Place, Room 1301, Boston, MA 02108 or call 617-727-8598. CONTRACTORS NAME - HANCOCK BUILDING ASSOCIATES, INC. Registration Number —100158 - Federal ID. Number — 04-2613675 Expiration Date — 6/10/06 This agreement is made on August 25, 2004 between Hancock Building Associates, Inc., 248 Mill Rd., Chelmsford, MA 01824 Tel(978) 256-2727 Herein called "Contractor", Salesperson Steven Mahoney 915 WHY Mr. William Appleton,'3-M Johnson St., N. Andover, MA 01845 Tel.(978-682 Hereinafter called "Owner". I. COMMENCEMENT AND COMPLETION OF WORK: Contractor will not begin the work or order the materials before the third day following the signing of this Agreement, unless specified here in writing. Contractor will begin the work on or about November 1, 2004 and completed on or about December 10, 2004. The owner hereby acknowledges and agrees that the scheduling dates are approximate and that such delays that are not avoidable by the Contractor and shall not be considered as violations of this agreement. Custom orders, special orders or specific colors of materials or products shall be chosen by the buyer in a timely manner according to the contractor's schedule. A second choice will be required should shortages, color, delivery or any other problems occur with any materials or products chosen by the buyer. In the event the customer chooses to wait for a specific product the customer should be aware that other delays may occur and possibly the delivery of the entire project according to the original schedule. Unless notified in writing by Hancock Building Associates, Inc. all custom orders should be completed and ordered within 10 days of the staff i of Hancock Building Associates original start time. Should this schedule not be possible please notify our office in writing immediately. II. CONSTRUCTION RELATED PERMITS: The Contractor under provisions of Chapter 142A of the General Laws is required to apply for and obtain all construction related permits. The Contractor shall not be deemed responsible for delays in the work described in this Agreement caused by regulatory, permit granting or inspectional agencies, authorities or individuals. Owner to provide Certified Plot Plan. Permits required for this job - 1. Building Permit Yes 2. Conservation No 3. Planning Board No PAj(MENT SCHEDULE TO BE AS FOLLOWS: I . Upon signing contract. 2. Upon start. 3. Upon halfway completion. 4. Upon completion of contract. $ 300.00 ,2�,� • � (�> � l � $10,000.00 $10,000.00 $ 4,415.00 TOTAL: $24,715.00 xcept for the Note: The above payments may tot be requested in exact order listed. (90% or more)ayments eA11 payments final payment are based upon substantial completion of thatp due within three (3) working days. "Unless otherwise noted within this document the contract shall not imply that any lien or other security interest has been placed on the residence." VII. ACCEPTANCE OF CONTRACT: Bove rices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to Thea p do the work as specified. Payments will be made as outlin..,d above. "Do not sign this contract if there are any blank spaces." CUSTOMER SIGNATURE: CUSTOMER SIGNATURE: CONTRACTOR SIGNATU� DATE ACCEPTED: 8/;? -//0q DATE ACCEPTED: rsigjo4 DATE ACCEPTED: :;- 25- O i Ll ui am c o •m u w c ;cam w a 0 0 a a C N O 00 u)V" •a Uw •O w°' w w a°' w w°' w rA 6 gr cn ui am U O O a O E Z y O C I c cm COD Q 'C O .CODg m m a �3 0 O L CL o�Q c CO cc CJ d O � CL C Z O V h c c c _c d CO) 0 LU U) 19 W 99 IIWww v/ c o •m c ;cam 0 0 C N O 00 •a •O CL c �vw m c o CD CD EQ L . : - c 0 CD .�-a o c ti ' 0= • US w$ c mi COL. E • ca m o O L (a cmm 3 H C 10a O C 0 cm ID LA O = -mg C CD r:ZZct � m . • o � wv�0 �•sZ o c O Q CC 1-- C Q Z NOS 30 H 0 d ~ to 4D.2 m W o~c Lu E C S c 5 -0 Z O cm h d •�O� = w J2 O =tea.1m5 U O O a O E Z y O C I c cm COD Q 'C O .CODg m m a �3 0 O L CL o�Q c CO cc CJ d O � CL C Z O V h c c c _c d CO) 0 LU U) 19 W 99 IIWww v/ TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that:........... � 10�1 ................................................................................ has permission to perform- ,t-', ........................ wiring in the building of North ..Mass. 4d c. ..... Li ... 5. i7niCAL INSPECTOR . ........ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ci n N2 ,� U 7 Date.Z� ..................... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that:........... � 10�1 ................................................................................ has permission to perform- ,t-', ........................ wiring in the building of North ..Mass. 4d c. ..... Li ... 5. i7niCAL INSPECTOR . ........ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 77MC0iW0NHE LTH0 AL1 -VS iGXS —M Office Use o I DLPARTIffiVTOFPUBUC'SAPE'IY Permit No. i47 WARD OFFMPRR VFVTT0NWGUT47Y0NS527CY1R12:00 Occupancy & Fees Checked APPLI(cA TTONFOR PF,RAIr To PF�oR1 vrELE=(= :4.L rho ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 ca 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover/� To the lnspe of s: The undersigned applies for a permit to perform the electrical work described below. IAP / PARCEL Location (Street & Number) e1 .. .. S G/,//ySOJJ Owner or Tenant /,y/ L/-�� ,[J ,O%i'k TG A-) Owner's Address —FbriA/SC&) Is this permit in conjunction with a building permit: Yes [�o (Check Appropriate Bos) Purpose of Building /? Utility Authorization No. Existing Service ld-V Amp!/IU / �f olts Overhead Underground = No. of Meters New Service Amps U/ Y1(jVolts Overhead [ i nderground = No. of Meters Number of Feeders and Ampacity - - Location and Nature of Proposed Electrical Work 01,66 iGC-� CN //ZC— /✓ECJ G A/1/r/f96L- f/vL,,SE , k�°i/ e A-,1vr.4 syr No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KV A No. of Lighting Fixtures Swimming Pool Above Below Generators KV A ground and No. of Receptacle Outlets No. of Oil Buenas No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARIAS 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 b OTHER- na I u r • :mr: ' am n I - :• n :u:nl. • .��: r ::a�. :•: ba • n: I ahla I`C I.o• '•a. I I of .. H r.::d •w.l.• .Czwr.�wcriaisortalegivaiaAo F Iha,&afiridcdM3ldpudcfsarmtotheOffim YESFLI-NO,• a:•r.• r:a• u•I•ar• I r • •• : • • :•a .•tr I ' • M :• I• • 1 I•' . '.ra• •ai v l u.• •au- Esbrntu:•ValtrdBecbcalWcik � hPecbmDWReqxs02d Rotx4a Final s*wduniffTrFtm&cfkury FMNINANE •: • i at w\ • • 1•' I ' ' E' I a w . .► I ua I .I ,r •• m • I, s a ec I ::n :• n e \tea.• I : w 1.1 al !1 aII'• II •:/ 11.I••I.N 1c .I wII :•'IIi (Please hone) Owner Ayent • • No. PERMIT FEE�, ��