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Location
No. Date —
N°"TM TOWN OF NOF'fHJANDOVER `
„ Certificate of Occupancy $_
-S, Building/Frame Permit Fee $ 16 35 .
4C, �t
MUS � Foundation Permit Fee $
SAC
Other Permit Fee $ Z ��
Sewer Connection Fee $
Water Connection Fee $
TOTAL
1. 955
Building Inspector
Div. Public Works
HIST T
4
Location
No. Date -Z 5
N
f f 10RT1�, TOWN OF NORTH-ANDOVER
Op Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
-2 C14USE
i
Other Permit Fee $
Sewer Connection Fee $ I
Water Connection Fee $ 7, j
TOTAL $
uild' Inspe tor,
(00 K/224963:12 1, on. ,
�� Div. ub . Works
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FORM 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 local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: /J0",40 Z J 11115-T.✓
LOCATION: Assessor's Map Number
Subdivision
Phone(") j a-
Parcel
Lot (s) 4.
Street /�,o y % __4 2 St. Number 90
************************Official Use Only************************
OF TOWN AQENTS :
Conservation Ad nistYator
Comments
1m
Town Planner
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Date Approved 1O11119 0
Date Rejected /� p
Al//tjpr 4/nA111�%S-
Date Approved 2
Date Rejected
Date Approved
Date Rejected
Date Approved
—
Date Rejected
Public Works - sewer/water connections
- driveway permit T-71- LJ
Fire Department
Received by Buil
1
lot
i
f A
Location
No. aaa I Date 7- P r�
TOWN OF NORTH ANDOVER
• o�
A
Certificate bf Occupancy $
Building/Frame Permit Fee $
31CHU5
Foundation* Permit Fee $
Other Permit Fee $
TOTAL $
Check # 12 G 9
+1�
65 U
Building Inspec
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO COWAUCTWAK
MOVATF, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
r 'r.: ...tp:.^'_.+ii i..+', -..i� .. - .,'. .., , a-xta .-„-..«c...�ac:'' ."f"'''`• ++
vz—
BUWING PERMIT NUMBER:
O� / DATE ISSUED:
r
SIGNATURE:��
BuildingCommissioner of Buil . Date
SECTION 1- SITE INFORMATION
11 Prq-ty Address,
1.2 Assessors Map and Pared Number:
Map Number Parcel Number
.1.3 Zoninglnfernudion:
1.4 PropertyDimauiom
Zarin District Pryosw use
Lot Area Frmtwtt
1.6 MUDING SETBACKS tt
Front Yard
Side Yard_ Rear Yard
RegWred Provide
Provided Required Provided
tp� >� �. 54)
1.3. FlWZ.osetd C �+tson
FbodZaa Mmic�l p Sib D40W Sys= a
SECTION 2 - PROPERTY OWNERSHHIPIAUTHORIZEED AGENT
2.1 Owner of Record
3
eve r"Itz
Name (Print)
ly
Address for Service:d
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Si tura'
Tal
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable 0
1License
/l n
h
-414
d Sue
`��
�'. S aid 711p3
d/9e y
LicenseNamber
Address
1
J' O
Expiration Date
igaeture
Telephone
3.2 Registered Home Imp wmnant Contractor
Not Applicable 0
/JO/�/? /� L • ��u�Odr
S
/.3 93 Q y
,
C ompany Name
•�UG �! _
Registration Number
I
dna-�
Expiration DW
S nature
Te e
SECTION 4 - WORKERS COMPENSATION
Wofkafs Compensation lasufanee affidavit must be oc
in the denial of the ismanoo of the building ermit.
Aimed affidavit Attached Yes .......0 No ....... 0
SECTION S Description of Proposed Work (d
New Construction 11
Accessory Bldg, Q
i
Brief Description of Proposed
SECTION 6 - ESTIMATED CONSTRUCfIOI
to
Exi stipgBuilding Or Repau(s) 4/ Alterations(s) 0 Addition ' ❑
Demolition a Other 0 Specify
Work:
rnc" .
Item Estimated Cost (Dollar) to be;�
Co feted hcant
_pa,. �, - !,,,.,
_
1. Building
50,
E
SECTION 4 - WORKERS COMPENSATION
Wofkafs Compensation lasufanee affidavit must be oc
in the denial of the ismanoo of the building ermit.
Aimed affidavit Attached Yes .......0 No ....... 0
SECTION S Description of Proposed Work (d
New Construction 11
Accessory Bldg, Q
i
Brief Description of Proposed
SECTION 6 - ESTIMATED CONSTRUCfIOI
to
Exi stipgBuilding Or Repau(s) 4/ Alterations(s) 0 Addition ' ❑
Demolition a Other 0 Specify
Work:
rnc" .
Item Estimated Cost (Dollar) to be;�
Co feted hcant
_pa,. �, - !,,,.,
_
1. Building
50,
(a) Building Permit Fee
Multiplier
2 Elecaical r n
(b) Estimated Total Cost of
Construction
3 Plumbin
Building Permit foe (a) : (e)
D �-
4 Mechanical AC Al
S Fire Protection A14 ja
6 Total 1+2+3+4+5
Check Number
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
611, S 150 A.
The debris will be disposed of in:
Al le
Signature of ermit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
�� ✓fie �anvrno�zuiea� o�✓T/�aasac�zuael�G
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 082763
Birthdate: 01/15/1957
Expires: 01/15/2006 Tr. no: 82763
"�- Restricted: 00
DONNA L DUPUIS
71 TUCKER ST
LYNN, MA 01904 Administrator
✓fie e. n onmmafdi a�✓�
Board of Building Regulatidns anfttan ar s
HOME IMPROVEMENT CONTRACTOR
Registration: 139309
Expiration: 6/27/2005
Type: Individual
DONNA L DUPUIS
DONNA DUPUIS
71 TUCKER STREET
LYNN, MA 01904
Administrator
JUL-10-2003 08:46AM FROM -HRH INSURANCE OT8-6T0-2213 T-815 P-002/002
ACMD. CERTIFICATE OF LIABILITY INSURANCE
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTED OF
HRH Insurance Agency of MA LLC ONLY AND CONFERS NO RIGHTS UPON THE
One Industrial AV'enue HOLDER, THIS CERTIFICATE DOES NOT AMEI
ALTER THE COVERAGE AFFORDED BY THE PO
Lowell, NPA 01851
978 458-1275
INSURED W
Donald F. Johnston, Donald F. Johnston
& Co., Inc. and Svnrise Homes, Inc.
114 Boston Street
North Andover, HA 01845
COVERAC28S
INSURERS AFFORDING COVERAGE
F-084
DATE(MMIDDI"
07/10/03
CERTIFICATCERTIFICATE, EXTEND OR
INSURERAIA.rbella Protection
INSURERe:Travelers -Insurance company
INSURER C, J~ _
INSURER D;
THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICA175-0, NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 132 ISSUED 04
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCr 18EO HEREIN 19 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE UmITS SHOWN MAY HAVE BEEN REDLICED BY PAID OLAiMS.
_
INSRLTR +IYM OF INSURANCE �� POLICY NUMBER �V�LICY EFr--Fdr V POLiC`( EJ(PIRAT(®AI�—� LIMITS
GENERAL LIABILITY
CO,VIVE�CIALQENERALLIABILITY
CLAIMS MAD EDOOCUR
EACH OCCURRENCE
$
FIRE DAMAGE Anyonotrot
s
ME0EXP(Any ono parson)
��
6
Pi ERSONAL & AOV INJURY
!
-
I3ENERALAGGREGATE
_
S
I PRODUCTS-CCMPlOPAGa
6—
GEN 'LAGGREGATE LIMIT APPLIESPER:
POLICY I PRO- 1 OC
A
AUTOMOSILELJABIL.ITY
ANY AUTO(E2
17803400000 12/27/02
12/27/03
COMBINED SIN3LE L WIT
aecidenq
S
BODILY INJURY
(Perpemon)
s25 0 (0 0 Q
_
X
ALL OWNED AUTOS
SCHEDULED AUTOS
1
HiREOAUTOS
NON•CWNEDAUTOS
BODILY INJURY
(Perweldent)
14500, 000
PROPERTY DAMAGE
(Pcraccldenl)
-
I$100,000
-- ,-
4ARAGKLIABIUTY
(
AU700NLY-EA4CC(DENT
3
OTHER THAN EA ACC
AUTO ONLY: AGO
y -
5
ANY AUTO
EXCESS LIABILITY
I_6AChOCCURRENCE
13
—� OCCUR i CLAIMS MADE
AGGREGATE
IS
i
6
DEDUCTIBLE 1
____�_j
RETENTION $
$
B
—�--
WORKERS COMPENSATION AND 16KUH99IX305103
01/27/03
01/27/04
IwcsTATu- oTH•i
iT��YLIMI
EMPLOYERS' LIABILITY
ELEACMAOCIAENT 16100,
_
000
E;L,DIScASE-EAEMPLOYEE
$109, 900
E,L.OISEASE-POLICYLIMI
$500 000
OTHER
I
DESCRIPTION OF OPERATnCNSILOCATICNGIVF-MICLESIRXCLUSIONSADDED BYENDORSEMENTISPECIAI-PROVISIONS
Operations usual to a home builder.
Town of North Andover
Attn: Building Dept
Town Hall
North Andover, MA 01845
SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE THE EXPIRATION
DATETHIREORTHE ISSUING INSURER WI LLENCEAVORTOMAILI.,O— PAYSWIUTTEN
NOTICET07HE CERfiFIOATE HOLDER NAMED TOME LEFT, BUTFAILURE70DOSOSMALL
IMPOSE NOOBLIGAMON CR LIABILITY OP ANYKIND UPON THE INSURER,ITSAGENTS OR
AUT ORIZED REPRKSF
INTATIVE
ACDRD 25.5 ('719?)1 of 2 #25261 BLIT O AC IRD CORMRATIQN 1969
JUL iG. 2003 9:01AM ARBOR COT L MORTGAGE � NO Q51 �„�zF. 1rc
%York Proposal :
Submined By:
Donald F'. Jrohhstot: & Co., hv-
114 Boston Street
No. Andover, M14 01845
Page ! of I
Mr. & Mrs Bove
90 Crray Street
No. Andbver, MA 01.845
1 PT
ii/ -C 6410rzC
(//"'x/9-`7303
-
,Tray 9. 2003
Dear Mr, & Mrs. Bove.
It is our pleasure to submit this proprial to do uwrt at your home Located at 90 Gray
Street, No. Andover, MA. 27nsJob entarils repairing ane Fatttrers Porch located in frau
of msting home. After doing a complete assessment of your current Farmers Porch we
propose the following repairs
I) Reprove and dispose of existing sir Posts and replace with six new Cedar Porch
Posts
2) Remove and &spare of all bodam raa"lings acid replace with new.
3) Remove and replace all to raflings and replace with new.
4) ,Remve aW replace all balusters Erisung balusters to be used . New to be used
in place of my balusters damaged during removal of railings
5) Pa Infor One coat Printer Two coats Finish on all Pasta balusters and railings
We propose to begin work on 7/10/03 and compleie work on or about 7/17/03.
This schedule +coald vary depending on weather co>tclrrrons.
Total Cost Stock andL4bor Two Thmxrn4 Five ffun*ed Yhrsee Dollars.
Payment ScJ+aMe as follows: $1,072.00 dire upon signing of contract, $J.432.00
due upopr competition of Painting.
Authorized ,Signature:
Date:
Custaa
Date:
Cmatr+ictiot: Supervi.sar, Doaald F. lalrnston & Co., ,Inc
,A
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e,79Location 7-1 1No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy
Building/Frame Permit Fee
$
$ 90
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
$
i Q 12/26/96 12:31
Building Inspector
49.04 PAID
Div. Public Works
Location_%''
No.3 Z Date Z -
e
TOWN OF NORTH ANDOVER
Certificate of Occupancy $ y�
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
C' j `829/97 10:33
$ 3 0 r -
Building Inspector
50.00 PAID
Div. Public Works
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CER11FICATE OF USE & OCCUPANCYf,
Tomin of North Andover
Building Permit Number -4j-7 Date
THIS CERTIFIES THAT
THE BUILDING LOCATED ON a
MAY BE OCCUPIED AS L IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND
SUCH OTHER REGULATIONS AS MAY APPLY.
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Date ..7 . it :.`............
TOWN OF NORTH ANDOVER
D
+: PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation .. �? !':::.? ................
in the buildings of .................................
at `-?.... !�,<'Z .�! ..:.T ....... North Andover, Mass.
Fee.'?..�-, ' .. Lic. No.... .:.. ...............2....... .
GAS INSPECTOR
Check # .-� C, '/ [,
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MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO GASFTTTING
(Print or Type) � � C
G �%%D %�KiIIOY��� MA Date 17 3 20� Receipt* -
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� Building Lo cation �D ' �' S1� Ownees Name
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Map:__. Lot: Zone: Type of OectipancysZ��/�*17
New p/ Renovation ❑ Replacement ClPlans Submitted: Yes ❑ Nom,
Installing Company Name EASTERN PROPANE & OIL, INC. Checkone:
Address 131 WATER ST. D -LAVERS u 01923 Corporation
Estimate Valueof work: ❑ Partnership
Business Telephone 800-322-6628 ❑ Firm / Co.
KI --f I ie ---A PhtmhPr or GaS Fitter
Certificate
INSURANCE COVERAGE:
I have a current li ' 'city insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes CNo ❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑
Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application Cl?�onethis requirement.
Owner C3 Agent❑
Signature of Owner or Owner's 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 bestof
a work and installations performed underthe pemitissued forthis application will be in compliance with
my knowledge and that all plumbin
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen Laws.
City /Town
APPROVED (OFFICE USE ONLY)
Type of License:
Plumber ignature of ' nsed Plumber or Gas Fitter
Gasfitter
Master License Number
Journeyman
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2ND FLOOR
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7TH .FLOOR
STH FLOOR
Installing Company Name EASTERN PROPANE & OIL, INC. Checkone:
Address 131 WATER ST. D -LAVERS u 01923 Corporation
Estimate Valueof work: ❑ Partnership
Business Telephone 800-322-6628 ❑ Firm / Co.
KI --f I ie ---A PhtmhPr or GaS Fitter
Certificate
INSURANCE COVERAGE:
I have a current li ' 'city insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes CNo ❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Other type of indemnity ❑
Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application Cl?�onethis requirement.
Owner C3 Agent❑
Signature of Owner or Owner's 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 bestof
a work and installations performed underthe pemitissued forthis application will be in compliance with
my knowledge and that all plumbin
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen Laws.
City /Town
APPROVED (OFFICE USE ONLY)
Type of License:
Plumber ignature of ' nsed Plumber or Gas Fitter
Gasfitter
Master License Number
Journeyman
I a.wd MM7/03
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9CAR0 CF F RF- PRy'1'v'MCN RECULAnONS S{"'7 CMR 1=0 11 7%%
APFLICr4TiON FCR PERMIT TO PERFORM ELECTRICAL WORK
AJI.work to be perie.med In accordance with the mA"aeluuKri Oce, Cade. 527 CwR 12.00
(?LEASc ?!?JJJT Ii = OR ME AL : =()RH&=QZQ Date
Cit:r or ?OW12 QED _ Ta the la;pectar of uirt:s.
y
The undersib ed applwes for a permit to'perfarn unric decer_hed below.
Location (StrCet,6. Number) ��/ _—_--
i
Owner or 1'enan
Owner's Addres.
L. nib permit in coni=ctian VW% s building permit: ' Yea'ro No ❑ (4::3eCWAppropriac$ Bax)
Purpose of Building Ko.
:xiscin'g Service Amps / Va1es ovtrhe:ad ❑ 11ndg'rd ❑ Ko. of N.eter.��`
ser-zce AMP-$ M -- - —Vans Overbe4d ❑ Uadg'rd ❑ No. df He ter.
r'
Nt-=tber of e'eeders and AepaeiCt
Loeatian and Nacure of ?ropased Electrical Park
No. of Ligtlt;ng Cutlets , No. of 2ct Tubs ! No. cf l'ransioraers z„A1
No. of Lighting : ixLures
Above r7in-
Swiaing ?oaI grnd. Md ,
Gene: scars K'lA
No. os UtepCIale Outlets
No. of Ctl Burners
jNo. ni Z-4ergeney Lighting
tt Bac-a^Y Units
No. of Switch out:let3
No. of Cas Burners
# rM M-Ak''1S No. of Zones
• Nr.. of 3e_ec__o"; and
Inigating Devices
No. of Saundin Devices
g
ho. c): SeIZ Concained
Detection/Sounding Devices
(—� t�mi.ci.oal n
Loc -a C1 Coifnet»t«onl�lCther
Ila . e_ Xan aesNa.
of Ai.r Ccnd. Total
tons
No. of Dtsp4sais
No_ of peat Total Iotas
tuaos T ns ftSi
No. of DLshuashars
Space/Area �8
No. of 1>t-lers
Heating Devices IBJ
i+o. of Water HeatersLaw
15i� sr Ballasts
nit:age
go. Hydro IL ---sage Subs
No. of Haeors Total HP
Alam Installation
7SilEtAtiCB CAVm=: Ptwsuant to the requixrments of Maosaa.ht atts General Ltud"
I have a current Liabili Insurance FvLicf including Completed Operations Caver:ge or its substancial
equivalent. YESJS NC 8 I have Submitted valid proof of same to thin of°ice: NO ❑
If Yvu have checked YD'S, please indicate the type of coverage by checking the appropriate box.
i
I1'f5IIRAHC3ka BOND ❑ 01M ❑ (Please Specify)
piratiOq tel
93timated Value of Electrirsl Work S(god
Rork to Start A/d If4 Inspection Date Requested: Rough Ftaal�
SLPed uMder the penalties of perjury:
FSR!! NumiCgionSIri . UC. Na.
Licensee Richard Sampson Signature LTC. NO. 000030
Address 7 Central Street'. Ar�in�tvn, MA 0217 Bus. S.e1. No. 6tto. 617-64�—
e -- —Alt. Sal. No.§,7-64§-7z0a
B ER'S INSURA = WAZM; 1. = #crape that the LLeenaem does not: have the insuranC9 eoveroge Or rts SU6-
stantial 'equivalent as required by Haasachusects General Latm and chat my signature on this permit
sPPlication waives this requirement. Owner ASent: (please cheek one)
__ Ieleohons No. Fm= FES S 447 o�
I �
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TR 2697 Date .... lO ... +. .. ...... .
QyNQRTh TOWN OF J1N^ORTH ANDOVER
e io ,e 1�0 CLW II CRL
p PERMIT FOR 9M INSTALLATION
This certifies that .G.C..
.....
.
has permission for its installation �� G c. •./Jsr
in the build'ngs of ..1 �.. ....yt/.."............. • ... .
at 0 .............. . . ort An er ss.
j_ �
fgt28 .1315 Ll�. NoC2;� CTO ...........
��� .INSPECTOR
WHITE: Applicant CANARY: 'i�ii i g Dept. PINK: Treasurer GOLD-
... .r+ly+vim ..� -v .1+' .. L..+ .w-..�.L. �sS..♦.r y ♦. . .. • ._.u, . . ... '1
4 /
T3 Date....4?
266.
F
NpRTM TOWN OF NORTH ANDOVER
0 y � `p PERMIT FORGA-rINSTALLATION
C=le C'f/1r�4/
C'
This certifies that QA '.................... .
has permission forgal"installation . !U-4 z .J...H.0im .9 .........
in the buildings of .16.00... Tq�` ..................
at �V .. � 4.�r....: t............ , North Andover, Mass.
4,6�4;" -4.0 240.00 PAID ,OA<INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
;\ Office Use Only
01 4e Lfommonmt# of 11tt000t4uolrtto Permit No.
+1epartment of Vuhlic 26afetg Occupancy & Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR.12.00 3190 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date ��� � 6
(X* or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to perform the electrical work described below.
Localtion (Street & Number)�� �`� "� ��+ t
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building -P ` '(u in Utility Authorization No.
Existing Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service ")— Amps On /_s .10/01ts OverheadP4Undgrnd ❑ No. of Meters 1
Number of Feeders and Ampacity
3 V
Location and Nature of Proposed Electrical Work
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws ,�/�'
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O I
have submitted valid roof of same to the Office. YES NO _ If you have checked YES. please indicate the type (of coverage by
checking the aR!;90riate box.
INSURANCE BOND OTHER L (Please Specify)
(Expiration Date)
Estimated Value of Electrical) Work S
Work to Start �n" f t!� Inspection Date Requested: Rough ��' � Final
Signed under th Penalties ofry: GL9�
LIC. NO.
FIRM NAM
Licensee h.6 �—CS 1 k�-= ' < Signature LIC. NO. r� —i
Bus. Tel. No. ���� �� `�
Address `_. Alt. Tel. No.
Q40 ST �.��
OWNER'S INSURANCE WAIVER: I am aware that the Licehsee does not have the insurance coverage or its su itantial equivalent as re-
quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent
(Please check one)
TePERMIT FEE S
lephone No.
(Signature of Owner or Agent) x.6565
Total
No. of Lighting Outlets ZtJ
No. of Hot Tubs
j
No. of Transformers KVA
No. of Lighting Fixtures
g 9
�a I
Swimming Pool Above
grnd. L_.
In-
grnd. ❑ I
Generators KVA.
No. of Emergency Lighting
No. of Receptacle Outlets
V
No. of Oil Burners
Battery Units
No. of Switch Outlets
u
No. of Gas Burners
FIRE ALARMS No. of Zones
No. of Detection and
Total
Ranges
No. of Ran 9
No. of Air Cond.
I tons
Initiating Devices
No. of Sounding Devices
No. of Self Contained
No. of Disposals Dis
P
No.of Heat Total Total
Pumps Tons KW
No. of Dishwashers
i
(
I Space/Area Heating
KW
Detection/Sounding Devices
Municipal
Local ❑ Connection F7 Other
1
No. of Dryers
Heating Devices KW
I
No. of No. of
Low Voltage
No. of Water Heaters
KW
( Signs Ballasts
Wiring
i
No. Hydro Massage Tubs
No. of Motors Total HP
OTHER:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws ,�/�'
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES O I
have submitted valid roof of same to the Office. YES NO _ If you have checked YES. please indicate the type (of coverage by
checking the aR!;90riate box.
INSURANCE BOND OTHER L (Please Specify)
(Expiration Date)
Estimated Value of Electrical) Work S
Work to Start �n" f t!� Inspection Date Requested: Rough ��' � Final
Signed under th Penalties ofry: GL9�
LIC. NO.
FIRM NAM
Licensee h.6 �—CS 1 k�-= ' < Signature LIC. NO. r� —i
Bus. Tel. No. ���� �� `�
Address `_. Alt. Tel. No.
Q40 ST �.��
OWNER'S INSURANCE WAIVER: I am aware that the Licehsee does not have the insurance coverage or its su itantial equivalent as re-
quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent
(Please check one)
TePERMIT FEE S
lephone No.
(Signature of Owner or Agent) x.6565
Date. 7_ ./.l..1,..-.. .
TOWN OF NORTH ANDOVER
P
PERMIT FOR GAS INSTALLATION
This certifies that.�......... J�.�......... ..........
has permission for gas installation C).r � � ..........
in the buildings of ...,��� /& .....49 ? ...................
at
Fee..a.5... Lic. No.,/
Check #
6,1
........ , North Andover, Mass.
GASINSPECTOR
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
,MA Date 0.)— Receipt# Permit#
G
Building Location - � - OwneesName'V'A)-- -fl a' <z. -
Map:
Map: Lot: Zone: Type of Occupancy>'.��/� / J�i�'i �'`Y Ale10116
New Cl Renovation f9' Replacement ❑ Plans Submitted: Yes ❑ No ❑
Installing Company Name EASTERN PROPANE & OIL, INC.
Address 131 WATER ST DANVERS MA 01923
Estimate Valueof Work:
Business Telephone
800-322-6628
Name of Licensed Plumber or Gas Fitter 4 ?:LAg X - AK
Checkone: Certificate
Corporation
❑ Partnership
❑ Firm / Co.
INSURANCE COVERAGE:
I have a current li lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked vees,,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Ul-seOther 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.
Checkone:
Owner Agent❑
of Owner or Owners 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 o
my knowiedge and that all plumbing work and installations performed underthe permitissued for this application will be in compliance with
0 jertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ggnerai Laws.
By
Type of License: i �i'�
Plumber iSignature of Licensed Plumber or Gas Fitter
Title Gasfitter �y9�
Master License Number
City /,Town RJoumeyman
APPROVED (OFFICE USE ONLY)
Revised 05!17=
�I
�m�s�aou�o�oao�n
nm�ou�omu�aom
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nsu�o�m��aoo�m
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NoSumom
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���vo�ovowmo��
Installing Company Name EASTERN PROPANE & OIL, INC.
Address 131 WATER ST DANVERS MA 01923
Estimate Valueof Work:
Business Telephone
800-322-6628
Name of Licensed Plumber or Gas Fitter 4 ?:LAg X - AK
Checkone: Certificate
Corporation
❑ Partnership
❑ Firm / Co.
INSURANCE COVERAGE:
I have a current li lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked vees,,please indicate the type coverage by checking the appropriate box.
A liability insurance policy Ul-seOther 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.
Checkone:
Owner Agent❑
of Owner or Owners 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 o
my knowiedge and that all plumbing work and installations performed underthe permitissued for this application will be in compliance with
0 jertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ggnerai Laws.
By
Type of License: i �i'�
Plumber iSignature of Licensed Plumber or Gas Fitter
Title Gasfitter �y9�
Master License Number
City /,Town RJoumeyman
APPROVED (OFFICE USE ONLY)
Revised 05!17=
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