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HomeMy WebLinkAboutMiscellaneous - 9 HEATH CIRCLE 4/30/201810531 This certifies has permissio Date ...,0/0/�........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING that-.—[Z ............................................. n to perform .41.0t. 404r'...664� ..... plumbingin the buildings of ............................................................................................. at ...... q ... We. -J4 ... O.P . .......... ........ jNo4 Andover, Mass. Fee.// ... Lic. No. ....................................... OCUMBING INSPECTOR Check # I -VA It. .A Date..... ....... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............................ r ..... . . . . ......... has permission for gas installation . ... .. I . ..... in the bui ings of at .......09140.......... Fee5: ........... Lic. No. 1 Check 9350 N rdAn over, Mass. �E .J ............................ Gs Ns `I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK l CITY ® _ Q r _ _ _ MA DATE ( PERMIT # JOBSITE ADDRESS C OWNER'S NAME Co i ca ✓lQ POWNER ADDRESS S TEL [__ �]FAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL ©[ EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES ® No Ell FIXTURES'l FLOOR- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE J DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND SYSTEM I — ._1 Tl ._ �_[ .___ �( — f € _A [ [ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM R-__[ [ f DEDICATED WATER RECYCLE SYSTEM i DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER i ___....i FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER F INSURANCE COVERAGE: 7 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO M IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY D BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNERF-11 AGENT 0 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc with al ertin t provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j PLUMBER'S NAME i 0 va _ ---1LICENSE # W_c�__q_ (yll7A�� MNATURE MPM JP © CORPORATION n#©PARTNERSHIP ®# _ ; LLC COMPANY NAME ;ADDRESS (' 1 Q CIT _r jq,yc f-� _ _j STATE j ZIP ` ( TEL $ �`t d FAX L CELL"T EMAIL o El z V1 ❑ W a Iii w LL The Commonwealth of Massachusetts Department oflndustritclAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 � www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ' w 4 Name (Business/Organi'zation/fndividual): __*Cz� CY. T Address: `4 kQ �f m a- or -I O, __r If S�-CfO - Q) ZrPhone City/State/Zip:�� Lt1 Are y� an employer? Check the appropriate box: - Type of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7• ❑Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9• Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing allwork officers have exercised their right of exemption per MGL I IMPPlumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12•[] Roof repairs insurance ] ired. re q u employees. [No workers' 1311 other comp. insurance required.] "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 anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP -WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. Ido hereby certlounder the pains andpenalties ofperjury that the information provided ave isIt rue and correct. e; ,,,�,,„ o•- / r ®vn �C�l.�•fJ A lata- brC 1 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. CitylTown Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other - - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire, express or implied, oral or written." An employed s defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states.that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced.aceeptable evidence of compliance With the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for conformation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only -'submit one affidavit indicating current Policy information (if necessary) and under "Job Site Address" the applicant should write ,all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massahvset€c Department offadustrial .Accidents QfRoe o Ilryestigatio�s 640 Wasbington. Street B ostont MA 42 111 Tel, # 617-727-4900 ext 406 or 1.-S7MASSM'U'- Revised 5-26-05 Fax # 617-727-7749 VAVWMace ansr/rl;a DRYER FIREPLACE FRYOLATOR F—I FURNACE GENERATOR — — - - - - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _—i. OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES J�rNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge ;and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent prlslon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — 1-1 -LICENSE �-7 e- PLUMBER-GASFITTER NAME C*k SIJNVURE A IVIP 0MGF EjI JP El JGF D LPGIE1 CORPORATION Ej# PARTNERSHIP 0#= LLC D#= COMPANY NAMEI ADDRESS CITY STATE R4 -N ZIP TEL FAX 11 CELLI =EMAILI MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE IC14 I Ll PERMIT# JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS11 TE ___IIFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Er CLEARLY I NEWT—1 RENOVATION: El REPLACEMENT: Rr PLANS SUBMITTED: YES 0 NOD APPLIANCES 7 FLOORS- BSM' 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER J L --I COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR F—I FURNACE GENERATOR — — - - - - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _—i. OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES J�rNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge ;and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent prlslon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — 1-1 -LICENSE �-7 e- PLUMBER-GASFITTER NAME C*k SIJNVURE A IVIP 0MGF EjI JP El JGF D LPGIE1 CORPORATION Ej# PARTNERSHIP 0#= LLC D#= COMPANY NAMEI ADDRESS CITY STATE R4 -N ZIP TEL FAX 11 CELLI =EMAILI rA H O z 0 H U W a w � o a z zC) Nrl W F- W U w �* F- W w CO a Ow w L LU w V a z a o a a 00 a a Q � s w F- LL H zz z 0 H U C�7 C�7 N a The Commonwealth ofVlassachusetts Department of IndustriglAccidents Office oflnvestigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leibly Name (Business/Organization/individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: - Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time) x 2. ❑ I am a sole proprietor or partner - have hired the sub -contractors listed on the attached sheet. 7. El Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance, g, [] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11. [] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.❑Roofrepairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] xAny applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or S elf -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certlo under the pains and penalties ofperjury that the information provided above is true and correct. Signature: - Date: Phone #: Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. PIumbing Inspector 6. Other - - Contact Person: Phone LI Information and Instrueflon's. Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confnmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill. in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications "Many given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Goxnzz nwealth ofMa..ssa vsf De,padment ofIndustdal Accidents Office of Investigations 600 Wasbingtoa Sfroet BQstont MA 02111 TQ1, # 617-727-4900 ext 406or 1-877 MASSA , Revised 5-26-05 Fax # 617-727-7749 u�ur_mace ant�frl;a ACOREIr CERTIFICATE OF LIABILITY INSURANCE MODY DATE (M12011YYY) 06/03!2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 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 cerlificate holder is an ADDITIONAL INSURED, the policy(ies) 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 Phone: (978)263-3500 Fax: (978)263-1438 GALLANT INSURANCE AGENCY, INC. 199 GREAT ROAD ! P O BOX 975 ACTON MA 01720 CONTACT. Gallant Insurance Agency, Inc. PHONE FAX (A/C, Na.Ext : (978) 263-3500 Nc : (978) 263-1438 E-MAIL ADDRESS: PRODUCER 30545 CUSTOMER ID: ' INSURER(S) AFFORDING COVERAGE NAIC9 06101115 INSURED TIMOTHY J BOUCHER PLUMBING &.HEATING INC. C/O DEBBIE BOUCHER Safe Insurance Co INsuRERA : Safety INSURERS : Safety Indemnity Co. 33618 INSURER C : Norfolk & Dedham Mutual Fire Ins Co 23965 4 ROBERGE DRIVE INSURER D: TYNGSBORO MA 01879 INSURER E $ INSURER F AUTOMOBILE X ri COVERAGES CERTIFICATE NUMBER: 39933 REVISION NUMBER: 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 CO� MITSSHOWNM HAVE BEEN REDUCED DY PAID CLAIMS - ILS TYPE OF INSURANCE '�R SUER WVD POLICY NUMBER POLICY EFF D POLICY P-Xv MID LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 5XI OCCUR BMA00008515 06101114 06101115 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED $ 100,000 PREMISES a "w"nce MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- IErT LOC PRODUCTS - COMP/OP AGG .$ 2,000,000 $ B AUTOMOBILE X ri . LIABILITY ANY AlJTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS 2434324 04/22/14 04/22/15 COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ 250,000 BODILY INJURY (Per accident) $ 500,000 PROPERTY DAMAGE $ 250 000 (Per accident) $ UMBRELLA LIAR EXCESS 11AB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOWPARTNER/EXECUTNE OFFICERIMEMBER EXCLUDED? I� 'Mandatory In NH) It yes, describe under DESCRIPTION OF OPERATIONS below NIA WE062462A 09/30/13 09/30/14 OTi{ X I W"$ TORY LIMITS FR $ E.L. EACH ACCIDENT 100 000 $ � '--- E.L. DISEASE -EA EMPLOYEE $ 100,000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) (;LkjItlCATE MULDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE �heres RD 25 (2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved The ACORD name and loan are registered marks of ACORD Of Locations d �l No.Date J2---5 j TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ G4her Permit Fee $ ; Sewer Connection Fee $ Water Connection Fee $ TOTAL .�� 11/26/ 2 14-.""25,04 $ ZS w Building Inspector PAID Div. 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