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HomeMy WebLinkAboutMiscellaneous - 91 HEATH ROAD 4/30/2018PO Box 55098 Boston, FAA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS. Ch. 139. Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: MICHAEL COOK and. KATHLEEN COOK Property Address: 91 HEATH ROAD, NORTH ANDOVER, MA Policy Number: HMA 0215868 Claim Number: BOS00051586 Date of Loss: 2/23/2015 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Joshua Terenzoni Claim Examiner 2/25/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3287 Fax: (617) 531-6648 Email: JoshuaTerenzoni@SafetyInsurance.com 14357 Date l/a;&/ .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that. has permission to perform .... 44 ..................... ................. . I plumbing in the buildings of .... f./. ........... I .................. ................................ CA D at ...... ­­ .... I ­­ -- * +1 * .0- * ZZ: * :� ­ t-, '*'*"*'** North Andover, Mass. Fee. 3 0............ Lic. No.,P�?-..� ..... PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBIN"OiZ TYPE OR PRINT I CLEARLY CITY MA DATE PERMIT# IV 00 TER • •1 • 'EDUCATIONAL1 ' SII NEW: MI RENOVATION: • 1CEMENT: PLANS SUBMITTED: `( NOM -1 FIXTURES I F OR - 1 • 1 .rel.-�.".HI��+������fi�r a.l����^ • • • • 1 W—t�tMMMFM— FM-1MMFM--F W OWN ■ 1 / ' I��ill(�t•'�IIII�I�ll�ll�ll!•E!lIII�JI11!l��� DEDICATED • I SYSTEMIlllll�dlIll !lt!I�II�Iil�!!1 DEDICATED ' MMMWMWWMWWMMMW 11EDICATED GRAY WATER!I: DSIII F—M— M1FWW1MM�FM— FW—�1MMMFM— FM—NEW F-0-0 DEDICATED t���l•U�II!!!�lil�fl�lllll�I{R111�1�1>111 M11�l�! � DISHWASHER i1llt1Fl�—F[C—JMIlX11�l!�l�lMI�1111111�1 1F�F�1iF�M— DRINKING •UN ' lI F�fM1 � FM - ••I • '• (Itlllll��l��l����lllIll�tl������ • •' /AREA DRAIN I�l��lll�#lt���l�■Iit1 INTERCEPTOR•�l�illl•�1 KLAITVCAHTEN FONFM ill�Sl�Ml i11>�111 11�t YS • • IFM—�FW-Il�llWllM--W �l {�1 l(R!!�!!! FW—FW-1! 1 FW -FW— J ROOF DRAIN SHOWER 11111�11�11>1111�111�1�IRlII�I!>'I�i�l�i SERVICE • • SINK ___ I!!!111111ft111111(tlil1•d�1�2i�tlllllu -FOILET MMll tllmiM1 51MMWMMM1! M ANAL FM-f®f® MFM- (M -FM -F IM----FMFM- fMFM- I NASHING MACHINE CONNECTION , i -,;NATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabiliiv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES [O'NO M IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d OTHER TYPE OF INDEMNITY Q BOND Fj 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 EJ AGENT Ll 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 incompli ce with all Pertinent pro ' io f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME !LICENSE #�iSIGNATURE MP lid JP _I CORPORATION Y i #LAM:_1PARTNERSHIP 0# f LLC E� COMPANY NAME t/�� _ ,dam, kDRESS CITY ,� USTATE _ i ZIP D/��TEL FAX �` ELL - - ! EMAIL CQ oo N O 4 r The Cognmonwealth of Massachuse& Department of bzdustriva[Accidents Office ofl avesiigataons _600 Washington Street Boston, MI 02111 mvw.m as&gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Led`bi�r Name (Business/Orgauization&dividml): � %1�, L (%/�%���� f �r Address: Phone #: Areyou an employer? Check the appropriate boa: 1. ('' -I am a employer with S 4. Q I am a general contractor and I - employees (full and/or part time)' have hired the sub -contractors 2. Q I am a sole proprietor or partner- listed 0-n the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. o workers' comp iIIsnmace required ] 3. Q I am a homeowner doing all work myself- [No workers' comp. insurance required.] t workers' comp. inc„rance. 5. Q We- M -e- a corporates and its, officers have exercised their right of exemption per MGL c.152, §1 (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. Q New construction 7. ❑ Remodeiing 8. ❑ Demolition 9. Q Building addition i 0. Q Electrical repairs or additions 11. 6lumbing repairs or additions 12.J Roof repairs 13.0 Other =>ny �_1te°nt =_hutWec:'c b--X-r MI aso hH c•.a"ec:: s�� c� s^ar~:Yg �; s _�•s' ^M^^�s'tion policy afo. Qoet T iomeowneis wbo submit this affidavit mdi, aimg they are doing aIl work- and titan him outside- must submit a new ai"ndavit indicating such. +Contractors tat check: this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. .J Iam an employer that is providing workers' compensataon insurance for my employees Below is thepolicy acrd job site information. Insurance Company Name: U / /cy z9z z Policy :; or Self ins. Lic. - ?WD 29,26Expiration Date: O�1114-1. J Job Site Address: City/State/zip: - I Attach a ropy 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 $1500.00 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 }nvestiga dons of thv MAL for i mn=ce coverage verification. I do hereby certify -uno the pains andperwlties of erjury thrat the informmion provided above is rrue and correct . Signature: Date: Phone 'QtTw-&Fuse only. Donor write in this area; tw-he-co&Tfi! -d by city or town ofciat City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Depaftment 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone N: Nil Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuantto this stag, an employee -is defined as "_every pe=rson -in the service of another under any contract ofbire, express or implied, oral or.written." An employer is defined as "an individnal, part aersbip, association, corporation or. otherlegal entity, or any two or mare Of the faregoiag 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 file owner of a dwelling house having not more than three aPmtmLents and who resides therein, or the occupant of the dwelling house of ano&w who employs persons to do mabt=ance, construction or repair work on such dwelling house or on the grounds or Wding appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter IA MC(6) also states that "every state or local licensing -agency shall withhold the issuance "or renewal of a &cense or permit to operate a business or to eanstruct buildings in file commonwealth for any applicant who has not produced acceptable evidence of coxupiiance with the insurance coverage required." AdditionaIIy, MGL chapter 152, §25C(7) status "Neitrer the commonwealth nor any of its political subdivisions shall enter inf3o any contract for the performance of public work trawl acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." ApFlia:ants Please fill out tie workers' compensation affidavit completely, by checking the boxes $sat apply to your situation and, if , necessary, supply sub-eontcactor(s} name(s), addresses) and phone numbers) along with their certificate(s) of insurance. I niitrd Liability Companies (LLC) or Limited Lie bMty Partnerships (LTX) with no employees-otl= bran the members or partners, are not required to carry workers' compensation insurance. If an LLC -or LLP does have t employees, a policy is required. Be advised $tai this affidavit may be sabmitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be wire to sign and date the affidavit. The affidavit should be returned to the oij�y or town tbat tine wlir..ation fhr tam peru&t of license is being requested, not the Depar=ent of Industrial Accidents. Should you have any questions rega:di rig the law orf you are required to .ontain a wofxers' r compensation policy, please call. the Department at the number listed below. Self-insured companies should eater their self-insurance license number on the appropriate line. City or Town Officials Please be sure that t3ie affidavit is complete and printed Iegbly. The Department has provided a space at the bottom of the affidavit fur you to $11 out in the event the Office ofInvestigations has to contact you regarding the applicant Please be sure to fill is the pemziillicense number which will be used as a reference number. In addition, an applicant that must subunit multiple permit/license applications in any given year, need only -submit one k$devit indicating current 4 - policy infomration (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 tine applicant as proof flint a valid affidavit is on file for fature 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 bum leaves etc_) said person is NOT required to complete this affidavit _ The Office of Investigations would like t &43* you in advance for your cooperation and should you have. any questions, please do nothesitate to ,give us a call The Departmenf's address, telephone and fax number. The Cznmonwwlth offMassachusetts Department of 1nduEstaial Accidents 40ce of hw sti ati fim 600 waddAgtan Street BostaA MA 02111 TeL # 617-727-49-00 -end 4106 or 1-8 77MASSAFE Fax # 6.17-727 7749 Revised 5-26-05 virwwmass-govkiia COMMOL OE A;CHiISETTS==`:==•° : PLUMBERS AND GASFI TERS REGISTERED.AS_A PLUMBING CORP -- ISSUES THE ABOVE LICENSE TO: :GEORGE- R .-LAROSE. ANDOVER - PLUMBINN6 & HEATI-NG _=C0_ AEGEAN DR METHUEN MA. 01544-1580 = 2322 _ 05/03/14: `=WIR lONWEALTH OF MASSACNWETM= ° .��IJ'�it��a��1�=-� lQl��'��:li;�,fc��6� 1b n"�" : o � _ n• o _ _ ` PLUMBERS AND GA ERS LICENSED AS A MASTER PLUMBER '': ISSUES THE ABOVE LICENSE TO:: :GEORGE R LAROSE _ i 744 ODILE ST NETHUEN MA 01844-423.3 9983 05/01/14 I W;. ,1 CO�111u10�1�VllEA1 TH OF MASSAC&� USEITS:<: 0 0 0 o `t°.1,2Y Lf PLUMBERS AND GASFITTERS Z.1-ICENSED AS A JOURNEYMAN PLUMBVR'- ISSUES.THE ABOVE LICENSE TO. "VEORGE- R ,.LAROSE _ %4.ODILE- .ST _TIETHUEN MA 01844-4233 I$723 05/01/14 : " 172552 = :` Date .........�t. �`1..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ......... .. has permission for gas installation .. j in the buildings of ....4woa�4-1-.1 ....`....... t. t�K.-.................................................. at................................................................................................. North Andover, Mass. Fee.. �........... Lic. No. .�.a '..... ....1. ........................................ L V GASINSPECTOR Check # (�/ 9074 ; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ Old _ MA DATEa / PERMIT # 0 6 i 4 JOBSITE ADDRESS' � OWNER'S NAME I 2rD G. OWNER ADDRESSTEL^+FAX _ TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUC TIONAL ® RESIDENTIAL CLEARLY NEW: 01 RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES EI NOEJI APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ I J f I I 1 I 1 BOOSTER— CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE- FRYOLATOR FURNACE .. f GENERATOR LTJ— JGRILLE GRILLE(- ._ INFRARED HEATER_, LABORATORY COCKS MAKEUP AIR UNITI OVEN POOL HEATER �I _ —t- I __J .--_I —J- TJ . ROOM/ SPACE HEATER ROOF TOP UNIT TEST _II_ II_.�Jl�� UMT HEATER_-_� { _ 1-j� UNVENTED ROOM HEATER i___ ___ 1 --- ._ ....WATER WATERHEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES fiarNO D I_F,YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY © BOND F C!WNER'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 hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate 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 th all Pertinen rovisio f t Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _D.rS� LICENSE # _3_( SIGNATURE MP DJ MGF 0 JP Ljj JGFQ LPGI © CORPORATION PARTNERSHIP [, f # LLC [�]1 #� COMPANY NAME/ CrY�it/�—NQ DDRESS p�d,is% - 42�._(Jjtl'__-lD-_v________ CITY %�%1� . / -_— — I STATE ZIP _ Q.�11TEL _ ,75-.._� FAX=V LSS CELL_ _ EMAIL all__ of�eHy�ml�ga� _ 4th►_ • Ca -- — -- Massachusetts General Laws chapter 152 requires all .employees 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 him, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation orotherlegal entity, or any two or more of the foregoing engaged in a joint enterprise, and including t1€ze legal representatives of a deceased employer, or tree receiver or trustee of an individual, partnership, association or other legal maify, employing employees. However the owner of a dwelling house having not more than free apartnzenis and who resides therein, or -the occupant of the dwelling house of another who employs persons to do maiatemance, construction or repair work on such dwelling house or on the grounds or bolding appurtenaritthereto, shallnot because of such employment be deemed to be an employer." MGL chapter .132," 32,'§ C(6) also states that "every state or local fucensing'agency shall withhold the issuance'or renewal of a license or permit to operate a business or to emnstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of comupiiance with the insurance coverage required. - Additionally, Mtn, chapter 152,.§25C(7 states "Neither fine commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work imp acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Please fill out 6e workers' compensation affidavit completely, by checking the boxes float apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Liniiied Liability Companies (LLC) or Limited Liability Partnersbips (LTA) with no employees- othw than the members or partners, ane not required to carry workers' compensation insurance If an LLC -or LLP does have employees, a policy is required. Be advised fliat this afadavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be surae to sign and bath the affidavit The affidavit should br, rchm=d t D tine city or town tliat, the Wplica� :ffir the purzmitof license is bang requested, zea: the Departm=-. of Industrial Accidents. Should yru have any q=fions regardimg the lar or ifyou are required to dot du a wozcers' compensation policy, please call flee Departmentat the number Listed below Self-inseured 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 lavw0gations has to contact you regarding the applicant Please be sure to fill in the pem►itllicense number which will be -used as a reference number. In addition, an applicant that must submit multiple permidlieense 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 first a valid affidavit is on file for f item permits or licenses. Anew 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 (Le. a dog license or pemuit to bum leaves etc_) said person is NOT required to complete this affidavit _ The Office of Investigations would _Im_7oe to Thank you in advance for your cooperation and should you have any questions, please do not hesiia6e to give us a call. The Departmeafs address, telephone and fax number.. The Commonwealth ofMassarhuse Department aff€ndustrW Accidents Of am of bwesfigafifim 6W wad&gton Sheet . Boston, MA 112111 TeL # 617-727-49-00 e& 406 or 14 77MASSAFE Revised 5-26-05 Fax # 617-727-7749 v w.masssgovfdia OP ID: CHCR CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 10/22/13 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 certificate 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: 978-688-6921 Macdonald & Pangione Insurance P.O. Box 428 Fax: 978-688-5350 104 Main Street North Andover, MA 01845 Craig S Childs cNAOMEACT arcoNo Ext): ac No EMAIL ADDRESS: PRODU Elt CUST ER ID #: ANDOV-7 INSURERS) AFFORDING COVERAGE NAIC # INSURED Andover Plumbing &Heating Co PO Box 262 Andover, MA INSURER A: Utica Mutual Insurance Co INSURER B: Quincy Mutual Fire Ins Co 15067 INSURER C : INSURER D : INSURER E: INSURER F tr0VERAGES CERTIFICATF NIIMRFR• oC1k1Iernul su urrcrn. 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. INSR LTR TYPE OF INSURANCE SUBR POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR 4481325 10/26/13 10126/14 PREMISES Ea occurrence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 + GEN'LAGGREGATE LIMIT APPLIESPER, X POLICY PRO_ RO LOC PRODUCTS -COMP/OPAGG $ 2,000,00 n $ e • AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ B SCHEDULED AUTOS AFV206229 10/26/13 10/26/14 PROPERTY DAMAGE S (Per accident) HIRED AUTOS NON -OWNED AUTOS $ $ X UMBRELLA LIAB [!X] OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS UAB CLAIMS -MADE CULP 448141 10126113 10/26/74 AGGREGATE $ 1,000,00 DEDUCTIBLE $ $ RETENTION $ A WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETORIPARTNER/EXECUTE N OFFICERIMEMBER EXCLUDED? EI N / A 4481326 10/26/13 10/26/14 STATU- OTH- MITS X ER E.L.EEACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Plumbing and Heating contractor SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Plumbing & Gas Inspector Building Dept AUTHORIZED REPRESENTATIVE 1600 Osgood St Bldg 20 #2-36 North Andover, MA 01845, U 19BB-2009 ACORD CORPORATION. All rights reserved. ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD COMMONWEALTH O ACHUSEITS =- ' ]ice°.\�rOJ�Ta��i►1��.i�+t0�7 7a,CY°.. ; - ��°_ _ -_ PLUMBERS AND GASFITTERS REGISTERED AS_A PLUMBING CORP=:- ISSUES THE ABOVE LICENSE TO: - ._GEORGE. R - LAROSE ANDOVER - PLUMBING &: HEATAG. CO. -.0 AEGEAN ` DR METH_UEN MA. 01544-15.80 2122 05/01/14 I725.�5 NCOMMONWEALTH OF MASSEACH uSE3'6' = PLUMBERS ANDGASFITTERS� LICENSED AS A MASTER PLUMBER::=' ISSUES THE ABOVE LICENSE TO: : -GEORGE R LAROSE Y- 44 ODILE ST ,HETHUEN MA 01844-423:3, 9983 05/01/14 :172563- d MMo"EALTH OF MASSACk_ USE'S` -T : p O �O~_�O �.on1 :l=fT':,e0.-DSO PLUMBERS AND AS RS " -=.ECENSED AS A JOURNEYMAN PLUMBE=R ISSUES.THE ABOVE LICENSE TO. GEORGE- R LAROSE " _4.ODILE .ST lETHUEN MA 01844-4233 =` =- 38723 05/01/14 y 172552 .:, Date.. ..... '40RTH 0* TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION - z SAC MUS I This certifies that ........................................... has permission for gas installation1........... in the buildings of . ..... ( ....................... at e.. ...... ...... North Andover, Mass. Fee Lic. No.."e.......... . AS *1 t 8 C;?O R Check# & 5830 MAS&UUUSEMUNFORMAPPY ICATONPORPMMTODOGAS% rDKG (Type cr Pent) nate NORTH ANDOVER,, MASSACRUSKM 91 1,art# 3 v --- Amount v'a Owner's Name Neve Renovation RcpbcMt ❑ Plans Submitted ❑ V ii iiiiiiiii•i�iiii�ii iiiiiMiiiiiiiiiiiMM= iiiiiiiiiiiMMMiiiiMM iii iiiiiiiiiiMiiMMM ",;do - r, NO ■ • , Name ofiweased Phm*w crGas FWw Il�I3►MUMM COVE Ihavea - - j►I�n VdiioywirssabsUm iaDi�aat Yes t0 MD❑ lfvnkbxmcbmW &Dbpaf 0 a bldWddwdw of 11 bm Pooriwcr=a=i4r ❑ Band p Ovowes bwacaoce WUM I am awae *d &*i'ioae W"WAtisMlWhWMPoaqI b9 142 a£the Mass. t,�enasliaws,aodtLtt�ysi�rineaQ�P�waiaes�s . t�toaa Owser ❑ Amnt ❑ I i embveaf dwa® best afay kwwbfte sad *stall pig west and Baas paIosmed nadeSAeaavt Issued tar its w icabion wilt be in capoe wig all patinmt pvvisiaus cftLeM S� Si!� s� -142otft ��- Plu nbw C0 Fater No 2 7 1 0 Date.//.. Ay" ./"�......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING *3 This certifies that T fes+ ...:.................. ......................................... has permission to perform ..................: ....:........................................................ wiring in the building of `..................................... !t' r Y at......................................................................... ,North Andover, Mass. � bfj.. � r •.-+ � r Fees: ... e' Lic. No: !fin i ELECTRICAL INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1t1CWLN1lV1V1VW1:r9L1HVCMAJ,"(,HVMJIN Office Use on] DEPARTAIENTOFPUBLICSAFM Perrr it No. BOARD OFMEPRE[�EW0ArREGULATIOA SS27CW 12* Occupancy &Fees Checked 'VA4PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat dD Town of North Andover To the Inspect r of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) C Y�A dAJ Owner or Tenant C 111,0 t./( Y t A J i i7 /1 et'" 1111f o. S. Owner's Address _ , Y/1 /y? L Is this permit in conjunction with a buildi5yermit: Yes ® No (Check Appropriate Box) Purpose of Building �� N 6 L`y L22/Gy Existing Service_gg�� Amps / Volts New Service U Oi _ Amps o /,A y0 Volts Number of Feeders and Ampacity Overhead M Overhead M Utility Authorization No. Underground No. of Meters Underground No. of Meters Location and Nature of Proposed Electrical Work owkl, IVA-16 a 7,711-77 f ez ,ft No. of Lighting Outlets No. of Hot Tubs No. ofTransfonners Total KVA No. of Lighting Fixtures Swimming Pool Above ground El Below ground Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting BatteryUnits No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections a No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER 11S" eCaaage PtasuataothetagtetanatsofMwsadiBcttsGmalLaws Iha\ea=utLiablityh>ua=PbbyffdudaMC CmaaWcritswbstr6aletg� YES a NO Ihawsu&rttedvaldptoofofsametotheOff= YES IJ F-1 ff}cuhatiedxdWYFS,pleaseindc&thetypeofwytra bydeddztgthe box llVS[Jft?N a BOND a O I%) M F-1 ft=Specify') Wo rk iD &vt -- ltspectial f e R4xsted Signed tsider r %xilties ofpeljt FIRM NAME 'Tl fy Lica�see �G7J A A J Y (7Jlt� ExpirAw Date Fwd Vaiuec Umftical Wok $ 1rmal A LiowseNa. Ljmwllb —04 D Btsine,� Tel Na AL C (mr Alt Tel Na X67 7 OWNER'SINSURANCEWAIVER,I.arnawa dxtthefkc se�lhea�rarneanaa oritss rgialat�mrala�aslegtmadby� Laws andihatmysigt�tseon the pamiion waitesthis lagttsenta>s. (Please check one) Owner M Agent ❑i Telephone No. PERMIT FEE L "3f 70 . P 34', '? , Date..% :................. TOWN OF NORTH ANDOVER " PERMIT FOR GAS INSTALLATION P 1. , This certifies that !:�� r L .:..' !::`.....::.. f ......... has permission for gas installation .. ... ........ ............ in the buildings of ...............:.......................... at ...: '�.. �...... !�............. North Andover, Mass. Fee.. .:.... Lic. No... :.....'. ............................ GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer g > MASSACHUSETTS UNT'ORM APPLICATON FOR PERMIT TO DO GAS FITTING Y f iType or print) Date 152r �0�6 NORTH ANDOVER, MASSACHUSETTS I Building; Locations 9// z— ,r—A `qui Owner's Name New a Renovation ❑ Replacement ❑ Permit R ✓ l Amount S Plans Submitted ❑ (Print or type)-C}eck one: Certificate InstallingCompany %%L fs ❑ . Name 116Corp. Address �� e V 4-e0,0 J ❑ Partner. ?F'Gy frS yt� U t� Business Telep 3, ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter / INSURANCE COVERAGE Check one: I have a current liabiiity Insurance policy or it's substantial equivalent. Yes No ❑ Ifyou have checked Nes, please indicate the type coverage by checking the appropriate box. Liability insurance policy � Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 1421 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 entere(J) In above appucanon are gruc snu ; "MIL« LU «11 best of my knowledge and that all plumbing work and installations per tormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter of the General Laws. By: Title City/Town APPRU1,ED (t)FFICi: 115E ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber / ❑ Gas FitterLIC-ise Numoer ❑ IMaster r7 Journeyman = c — In GG — In ie. Zrn Z J n ::d :ti — — — _ z B k S E .M E `I'r I Tr F L 0 0 R 2 N D. F L O O R 3 R D. F L O O R .4TII. FLOG It ST II. F1, 0R 6T II . F 1, 0 0 R 7'r 11. FLt) O R BT II. FLOOR (Print or type)-C}eck one: Certificate InstallingCompany %%L fs ❑ . Name 116Corp. Address �� e V 4-e0,0 J ❑ Partner. ?F'Gy frS yt� U t� Business Telep 3, ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter / INSURANCE COVERAGE Check one: I have a current liabiiity Insurance policy or it's substantial equivalent. Yes No ❑ Ifyou have checked Nes, please indicate the type coverage by checking the appropriate box. Liability insurance policy � Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 1421 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 entere(J) In above appucanon are gruc snu ; "MIL« LU «11 best of my knowledge and that all plumbing work and installations per tormed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter of the General Laws. By: Title City/Town APPRU1,ED (t)FFICi: 115E ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber / ❑ Gas FitterLIC-ise Numoer ❑ IMaster r7 Journeyman Date. A�- . 2. /: < .- N2 464.8 HpRTp TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING SSACHUSE This certifies that .. ?. /X ........ , . has permission to perform .... J1. plumbing in the buildings of ...T"�, 'J ..! .................. . at .. � .. .�f { l / `( .... , North Andover, Mass. Feet?!) :..Lic. No..`3. .� `..`. ........ � ..-!�.�.,...�._..... PLUMBING INSPECTOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer .a@ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT --TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS �/ Date Building Location 9� ffi TN 131 Owners Name /I7 f%/GA—/r4 So/�i Permit Amount Type of Occupancy / — /� /// /y t/ New Renovation Replacement Plans Submitted Yes 11Plans (Print or type) Installing Company Name t/h rTF AG Address Check one: Corp. MPartner M Firm/Co. Name of Licensed Plumber.G,GOi�6F i� ISTT,F Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: F]Liability insurance policy Lj Other type of indemnity n Bond Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have 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 Plumbing Co¢e� id Chapter 142 of the General Laws. y: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License icense i um er Master F� Journeyman 0- • i `9 I ■■■■■■■■■=■■■■■■■n■W■■■■■ .. • no WWnMW=M■MMMM■■■■■ MMMMM EWA' )W.. • �■e n■■■■■■■■MMMMM■■■ MMMM i ., ..• MMWMMM■■■■■ MMMM■■■■MMMMM■ . I • • • mmmm■■■mmmmm■■■■ mmmm■■■■■ ■ I • 9• • • ■■■ MMMM■MMMM■ MMMM ■■■■■■■■■ I: 19 [OW! MM■MMMM■M■i■ MMMM■i■ MMMM■■■■ ■ 1• • • • ■i■M■■ MMMMMMMMMMMMM■■■■■�■■ .. • ■■■iM■MMMM■■■MM■MM■MMMM■■■ (Print or type) Installing Company Name t/h rTF AG Address Check one: Corp. MPartner M Firm/Co. Name of Licensed Plumber.G,GOi�6F i� ISTT,F Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: F]Liability insurance policy Lj Other type of indemnity n Bond Certificate Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have 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 Plumbing Co¢e� id Chapter 142 of the General Laws. y: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License icense i um er Master F� Journeyman 0- Date ..... � �1",g �lJ... N2 2442 ....... NORTIy TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ........ ....... /%i........................... has permission to perform ........ ......... . .................... wiring in the building; of ... C` ...... > at ....... ...... North Andover,lAws. Fe/j ... 0.,.k Lic.No.J..w ../q ELEcrRicAL INSPECrOR Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer THE COMMON THOFAUMCHUSEI7S Office Use only �OFPlII3l.ICSAFEiY Permit No. BOARD OFFNEPREVEMONREGUlAHOAS527CMR12.00 Occupancy & Fees Checked APPLICATIONFORPF,RAIRT TOPSUORIVIELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 ff (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover The undersigned applies for a permit to perform the electrical work described below Location (Street & Number) 689 -0/0% Owner or Tenant e. f ` l" l Owner's Address Is this permit in conjunction with a building permit: Yes Q No Purpose of Building Existing Service Amps / Volts J Overhead New Service 14n2 Amps / Volts Overhead 3 .'Fiber of Feeders and Ampacity Location and Nature of Proposed Electrical Work To the Inspector of Wires: PARCEL (Check Appropriate Box) Utility Authorization No 00 V-7.50 Underground ID No. of Meters Underground r__J No. of Meters No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ground Pround No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. 'fetal Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices Nc A Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Laval Municipal Other No. �f Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP OTHER- - •• 1 I 1 111 d •. �. i(" . p:.l l.• . .� � ...:- • Il ` .. ✓.I :1 . :. I ` i0 III':. : 10 • ••: •' `:i .• I ".'11 �" •Ot► W. . • • :•�:• 0 ��- I 01 NI;' 1 ." •' ••' : �' / • :••I ? 1 - .i00 •0.1:1!' 0•' .NI� .�11 101 .11.•. .ill" "11 :I!:1 - •' M 6011 ✓. • 1 •.1 !• �✓.1 /`� � IIQO:•1.•. LII- • :• w`I:0 � • �1 I bignedmcler »r lao w reNce. UCC.-N^r(_aJ co, Iio=1116. 11019 74 Litialsee I ',fir .-�5 (.5�? w 1^Q ►.� C� signattzue Iira>seNo /��^ BtEirmTal ,b- 6 b t ii OWW Q SINSURANCEWAN ER;1amawarett>atttiel==dmnut tra andttvirnysig ntinonimparilapplioatimwaiwsdmiegxi mxri (Please check one) Owner M Agent Signature of Ow-ner or Agent Alt. Tel. Na i edbvMsadaolLsCxn=1Laws Telephone No. PERMIT FEE $ _f'D ' Ot Location /_�� " �� �a, No. 0 ( © Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ 6-7 Building/Frame Permit Fee $ Foundation Permit Fee $ �- Other Permit Fee $ TOTAL Check #" 13 Building Inspector _J Location No. �/r Date NaRTM TOWN OF NORTH ANDOVER 16. Certificate Occupancy * ; , of $ +,�s''•°''tom sACH Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL /,--5 �'-� $ Check #/4/ 14L 28 � r. / Building Inspec e TOWN OF NORTH ANDOVER - BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING .fol : kid �BC`�rilC , ;: , r. . �,.----- BUILDING PERMIT NUMBER: - DATE ISSUED:f7s s o �� I OOF SIGNATURE: I Building Commissi7ner/InECEtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Addr 1.2 Assessors Map and Parcel Number: 1�4/ Map Number Pardi N mber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning Dis–u ict Proposed Use Lot Area'sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Re uired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: �I 1.8 S werage Disposal System: Public Private 0 Zone Outside Flood Zone JK Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record C 9)erld / �2' � h 1L -G� Na . �(P nt) Address for Service : e Telephone 2.2 Owner of Record: , �r Name Print Address for Service: Si naturq Telephone SECTION 3 - tONSTRUCTION SERVICES 3.1 Licensed Codstruction Supervisor: Not Applicable ❑ ZI) �;!! Licensed nstruction Supervisor: a p o g License Number ve.)s Adder— / C� Expirati n Date Sig m Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone M rn X ic Z 0 0-1 v rn 8 IN 9/ ,0a,I�le:v /J.01J{ C 4'e To MAScheck COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.01 Release 3 CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: 1 HEATING SYSTEM TYPE: DATE: 7-13-2000 COMPLIANCE: Passes Maximum UA = 782 Your Home = 775 or 2 Family, Detached Other (Non -Electric Resistance) Permit # Checked by/Date The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310—and J4.4. Builder/ Des igne Date hw4d / j. Area or Cavity Cont. Glazing/Door ------------------------------------------------------------------------------- Perimeter R -Value R -Value U -Value UA CEILINGS 3296 0.0 19.0 158 WALLS: Wood Frame, 16" O.C. 2766 0.0 19.0 230 GLAZING: Windows or Doors 649 0.350 227 DOORS 42 0.450 19 FLOORS: Over Unconditioned Space 3278 0.0 19.0 141 HVAC EQUIPMENT: Furnace, 90.0 AFUE ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in Sections 780CMR 1310—and J4.4. Builder/ Des igne Date hw4d / j. 6-' CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE.1 "=40' DATE. 7/14/2000 Scott L. Giles R. P. L. S. Frank. S. Giles 50 Deer Meadow Road North Andover, Mass. I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BY LAWS OF NORTH ANDOVER WHEN BUILT OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. N ZONE. IS R-3, 13972 CERTIFICATE OF USE &OCCUPANCY Town of North Andover Building Permit Number �0� 8 Date /_30 a061 THIS0CERTIFIES THAT THE BUILDING LOCATED ON / j��� Cl MAY BE OCCUPIED AS Sim j� /til /`� ��U�/ �q IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS SUCH OTHER REGULATIONS AS MAY APPLY. C/ j?ovIns; 3.5 �3 ths, 3 Sia# A#W d ZICl�e�50�` R01 Building Inspector STATE BUILDING CODE AND CERTIFICATE ISSUED TO ADDRESS 4- Cf) M C m C/) 0 m a CO) 0 Z CD �r sus � CL �. Q 0 v a� c� CD o C) C O CO) .0 O CO) Cl) c 0 C Cn cc 0 CD It CD CO) CD CO) cn n 0 V J C n 0 z C� V/ r� r: CdC: L: n O n A �• fAG Q N SoEm CA O � m n m C7 CO CA M Z N• m == N• = °:m Co CL •+ a o Fn - Sr -1O m H O CA O m CD n .0No :� n -1 i0 O• p O '� ••► O G y: n .� Som Er CA C`n a a N � CL . 0 m N cm cc c a -, l" CDIt a� CC Ca -O•` d y, s m H CO) � � dm N� �y . zm O O 7 � h o :k: CD ACAfar A CD s� `CD a� h .c N O O CRU ' O d O_ o:6 V1 Ccp7 r.notcn Cl f O C Town of North Andover pORTH Building Department �,? gt`. �6`a �L 27 Charles Street tit North Andover, Massachusetts 01845 * ,� (978) 688-9545 Fax (978) 688-9542 CO[111C CWKM ��SSAC HUs���y APPLICATION FOR CERTIFICATE OF OCCUPANCY / INSPECTION ADDRESS // M LOT NUMBER SUBDIVISION DATE REQUEST FILED DATE READY FOR INSPECTION � il/ �b o2 a V FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY-FIVE ($25.) DOLLARS WILL BE CH.A-R GED IF THE STRUCTURE DOES Nk"J"T MEET ALL APPLICABLE CODES. SIGNATURE OFFICIAL USE ONLY ROUTING CONSERVATION PLANNING DATE—( Z 61 D.P.W. - WATER METER DATE d-2 b D.P.W. MUST INDICATE THAT WATER METER HAS BEEN INSTALLED PRIOR ,Tffis INS-P-ECTION REQUEST DATE. SIGNATURE / DPW AUTHORIZATION RC %`_ JAN 2 2001 NORTH ANCOVFR CONSERVATION COM iSSION VA, SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be comp d su itjp�with this appli ti o pride this affidavit will result in the denial of the issuance of the buildingit. J*4 Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction Existing Building ❑ Repair(s) ❑ Alterations(s) 0 Addition 0 Accessory Bldg. ❑ Demolition 0 Other 0 Specify Brief Description of Proposed Work: C0j1j e 'N ) Yo Qcz SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be OFFICIAL USE ONLY Completed by permit applicant I . Building (a) Building Permit Fee 6,5-0 Multiplier 2 Electrical (b) Estimated Total Cost of �V� D �j ' Construction / / 3 Plumbing Building Permit fee (a) X (b) 5'0 o P 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby au e= -' to act on behalf, in 11 t aners relatfvWtowork authorized by this building permit application. Si iiatureol Ov<��er Date SECTION 7b OWN ,R/.AUTHORIZED AGENT DECLARATION I 2ult n As Owner/Authorized Agent of subject �r erty / �` Hereby deL are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge . and belief 6 Pri `Na �e 5r ature of er/A ent Date NO. OF STORff?S SIZE BASEMENT OR SLAB j a s A44 nxi 7" SIZE OF FLOOR TINIBERS VNJ2NL) 3KD SPAN / &J DINIENSIONS OF SILLS y DIMENSIONS OF POSTS y DIMENSIONS OF GIRDERS 1A HEIGHT OF FOUNDATION THICKNESS %O SIZE OF FOOTING / d X "-70 MATERIAL OF CHIMNEY JF-40- 3..GIS ISBUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE 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 or requirements. AFFLICANT FILLS OUT THIS PHONE 6 k / 0 ! PARCEL LOT (S) ST. NUIVISER20z APPLICANTJA I/J J OZC LOCATION: Assessor's Map Number / SUBDIVISION, STREET OFrICIAL USE ONLY I RL- MNENDA"IONS F TOWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS -0, �^ TOWN/iPLANNER COMMENTS ' FOOD INSPECTOR -HEALTH PECTOR-HEALTH DATE APPROVED; DATE REJECTED -7 �,-[ t d � /�' DATE APPROVED /Uy/UO DATE REJECTED DATE.APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ COMMENTS zZ�)17_'1_ —�- PUELIC WORKS - SE7)NER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT- �_' /'nLJIS RECEIVED EY EUILDING ii ISPECTO Revised 9197 im 1^ DATE • tvll'o�o,-qde-) Growth Management Bylaw Exemption Statement Town of North Andover Euiiding Department Timis form shall be used to assist the Building Department in their determination of exemcdons under sec::cn 3.7 ,5 of the Town of,North Andover Grcwth Management Bylaw. Toe building acpliczrit shall provide all of tLe necessary infornnaticn as requested below. Na Mel cf Appli rant c= jidina Permit (be!cN) Address of Frccerr/ f r ' Mr;,i b ) Mao and rcal : r P.:r.Cse o Appliccticn (check below) Phc N ,ber of App' ant Single Famjly — Two Family I the undersigned applicant fcr the above property attest that the attached building permit -Cr which this form is =mpleted does compiy with the E<EMP7(3N section 8.7.6 of the North Andover Growth Management Eylaw. I also underand providing this form does not absolve me cr ary parry to this permit from the requirements of obtaining other permits required prior to the issuance of the _uiiding Permit. Further I understand that my interpretation of the E<1=MP7ION status is subiec; tc review by the Euildinc Department and is only of c: ally a:_--pted when the Euilding Permit ig issued. Eased on seclicn 8.7.e of the North Andover Growth Eyiaw the above lot and the work as acciied fcr on the above lot, in the building permit application and associated attachments, complies with one cr more of the following sections as indicated by a check mark. VThis is an acplicotien for a building permit for the enlargement, restoration, or reccnstruc icn of a dwelling in Zexents as of the effective date of this by-law, provided that no additional residential unit is created. The iet(s) were/was eeated prior to May 5, 1996 are exempt from the provisions of ;his Sec :cn 9.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the =ncitions of 8.7.5.care met and/or represents Dwelling units for senior residents, where cccioancl of the units is restrfGed to senior persons through a property executed and recorded deed restriction running with the land. For purposes of this SecCon "senior" snall mean persons over the age of 55. �l This application is a part of a development project which voluntarily agreed to a minimum 413% permanent recucdcn in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable aces and permanently designated as open spats and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Remotion, Conservation RestriGion, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This apptictlon represents a tract of land existing and not held by a Developer in common ownership with an aclacent parcel on the effeGive date of this Section 8.7 shall receive a one-time exemption from the P!anned Growth Rate and Development Scheduling provisions far the purpose of constructing one single family dwelling unit on the parcel. This application represents a lot whic't is ready for building permits,(i.e. all other permits from all other boards and commissions have been received and the project is in compliance with those permits), and the Oevelccment Schedule does not ac=mmcdate issuing a building permit in that Year, one building permit will be issued per Year per Cevelapment until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved fort U with this E(EMPTiGN, Please provide any and all information that would assist the Euiiding Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. Ey signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an E<ENIPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowle a or not,. -gm nds for refusat by the Euilding Oepartment to issue a Building Pe o 'gnature of wner or Aur onzad Agent wno signed the Attacned Building Permit Oate is-formy ust be attached to the Building Permit upon application for such permit. _ M,( The Commonwealth of Massachusetts >` .1 Department of Industrial -Ac c;dents GF, ice of Investigations Boston, Mass. 02 111 —„�/ Wcrkers' Compersatien Insurance .4�rrdavit Flame Please mint I am a homeowner perrcrminc all wcrx myse!r. j I am a sole proprietor and have no ane'Ncrkina in any capacty am an employer providing workers' compensation for my employees working on this job. /7/& _A/C _.. V v Address ;2 !2fx s7'L r /✓-s r ` City Phone t Insurance Co. 'S Glcel Y Comcanv name: Address Citr Phone Y, Insurance Cc. Folie Failure to secure coverage as ,ecuirec under Sec::cn 29.A or MGL 192 can lead to the imccsition cr camiral penalties cr a nne up to Sl, 9u0.CO and/or one years' imorscnment as •.ve:l as c:vii penalties in the r.crrn (=,a STCP'r/CRK CRCER and a Fine cr (5100. CO) a day against me. I understand that a =-y cr this st3ement maybe fcrvarced to the Or`ice of Investigsncns cf the CIA rcr coverage verinc`ticn. I co hereby csrtiry uncar the Pains and cenalties or perjury that :he infcrrraticn )creviced accve is 7ue and cored:. Signature—r—ate Print name Phone Ir Offic•al use only de not write in this area to be =mcle:ec by u^/ crown cmc:Zt C'ty or Tcvn P�rmdll c�nsire ❑Check ,f immediate resperse s required C.:rrac: ,:erscr: )chore T: Building Cept Ucensing `card ❑ Selectman's O,fc�e C Health oepartrnent Other Ulll � O UI m O a)0 j Oa n7 N C7r* p Z A D M " -. •* "? 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N o CS H a < m ti d 0 m C7 C7 do M O H -CD Z .0y, ._+ w to m N T CD a?m = y OCl) (A o V P14 i m CA m a o c ' C co O C y nCD CL CD CDcc- N ca c0 c a M m CD :� CA C C CC- C= 0' CL CO) U < : C C/) ? m CD CD mCD d H :� Ne: Cckit n :��� ** TO �. 0 ., Z CD H n mCD n ➢ H'' { _ m CD ••1 (n m :`: �p"Q A O C.0 CD ~ OoCO w 0 w n cn w G as 1 o d 0 0 C w cn C17 o n asrD C r w r o CD o O LC O ~ o • ~ z% �y w 0 w n cn w G as w C w cn C17 w n asrD C r w r In 0 R n o O a 0 c i Location C/,// r N y/' ' ;%/ _ No. ��� Date NORTH TOWN OF NORTH ANDOVER f 9 41 Certificate of Occupancy $ ;�s''•a° ^ E<�' Building/Frame Permit Fee $ C14 Foundation Permit Fee $ Other Permit Fee �!$ ' TOTAL $ � Check # C 13 8 C 2 Building Inspector r - TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING TV BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Nu ber 1.3 Zoning Information: Zoning District Proposed Use 1.4, Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required I Provide R red Provided Required Provided ( J 1.7Wt Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public Private p Zone Outside Flood Zone 1.8 ;erage Disposal System:V Municipal On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record A / Oi N �e J Rsyj 1a �� ✓V Name (Print) Q Address for Service v �v Signature Telephone 2.2 Owner of Record:% / Q ���Vh �e -r/ ✓�2 L° Z���/ rl r- v 1 Name Print �j dress for Service: Signature Telephone SECTION 3 - CONSTRUCTION 3.1 3.1 Licensed Cons ction Supervisor: a Lp� I icensed nstruction Supervisor: ,� 4, <--G'�� � � Al � 5 y A/-.12, Ivy Address' �J .gna a Telephone Not Applicable ❑ ej 0 9� License Number O Expi tion Da 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone W1 z M 00 10 M rM z G) ti SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work(check au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ JAddition ❑ Accessory Bldg. ❑ Demolition Other ❑ Specify Brief Description of Proposed Work: kX lz2 c� Lt/ e US �/ r� ✓� /.e �Z SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Co#ipletedbypennit applicant ;; 0FF1CIAL USE,U LY 1. Building �} �V d (a) Building Permit Fee Multiplier 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 SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner/Authorized Agent of subject property Hereby authorize 4 to act on My behalf ' 11 ri�A(err>s,Flativ o work orized by this building permit application. Signature of Owner r Da SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 4 as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief �y Print Nam Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIlvIBERS 1 2 ND 3 777 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Town of North Andover * AORTN OFFICE OF 3� �, a° COMMUNITY DEVELOPMENT AND SERVICES 27 Charles Street `. North Andover, Massachusetts 01845 WILLIAM J. SCOTT SSACHUSE Director DEMOLITION OF BUILDING AFFIDAVIT (978)688-9531 Fax(978)688-9542 DATE WA42 OWNER'S NAME & ADDRESSS� LOCATION OF PROPERTY TO DEMOLISH / /�5 r k.Y.,' DESCRIPTION' L) CONTRACTOR'S NAME & ADDRESS , 4✓ <� 1114A - U QS DEPARTMENT SIGN -OFFS 4_Z_� -ZC) 1 DEP . OF PUBLIC WORKS — WATER:�� GU SERVER: f CCAS IV TELEPHONE CABLE TAXES Jb"f POLICE FIRE ,� IIM�u ii`i �e 6 5 I r� �. �, ziJ_ C✓ �ii�J�5711�°`' EXTERMINATOR c, DUMPSTER — ON/OFF STREET tri /.✓ �' DIG SAFE NUMBER D / 9 D 0� DATE RECD BLDG. INSPECTOR BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 A/FORT/® PRODUCER M.P. ROBERTS INS AGCY INC 1060 OSGOOD ST NO ANDOVER MA 01845 .............................. INSURED OGUNQUIT HOMES INC 345 STEVENS STREET NORTH ANDOVER MA 01845 ISSUE DATE (MM/DD/YY) 5/03/60 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 COMPANY A LETTER COMPANY B LETTER :.......................... COMPANY C LETTER COMPANY D LETTER .......................... COMPANY E LETTER COMPANIES AFFORDING COVERAGE ....................... _........ _...... _..... I ........... _............. _................... GUARD INS GROUP _.................................... .. 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. ..................... ..................... .................. .............................:........................................................................................ ................................................................ CO : POLICY EFFECTIVE :POLICY EXPIRATION: LIMITS TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE ...................................................................................... $ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ CLAIMS MADE: OCCUR.: PERSONAL &ADV. INJURY ................. $ .................................... ...........: OWNER'S & CONTRACTOR'S PROT.. EACH OCCURRENCE $ FIRE DAMAGE (Any one fire) ......................... $ ........................ .. ............................................................... .......... ................... MED. EXPENSE (Any one person) $ :AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT ............................ .. ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) ................... ;......... HIRED AUTOS BODILY INJURY $ NON -OWNED AUTOS (Per accident) GARAGE LIABILITY .........: PROPERTY DAMAGE $ EXCESS LIABILITY EACH OCCURRENCE .................................................................... $ I IMRRFI I A FnRM AGGREGATE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS TOWN OF NORTH ANDOVER ATTN: BUILDING INSPECTOR CHARLES STREET NORTH ANDOVER MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPAN IJLS.&GENTS OR REPRESENTATIVES. rod fnd. CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MASS. SCALE. -I"--40' DATE: 2/25/2000 / Scott L. Giles R. P. L. S. Frank. S. Giles conc. bound 50 Deer Meadow Road fn d. North Andover, Mass. THIS LOT IS NOT IN A FLOOD HAZARD ZONE. \s- THE ZONING DIST. IS R-3. LOT #15 33,060 S.F. PLAN #3731 N.E.R.D. ASSESSORS MAP #91 PARCEL #41 �' B8 x I CERTIFY THAT OFFSETS SHOWN ARE FOR THE USE THE OFFSETS OF THE BUILDING INSPECTOR ONLY SHOWN COMPLY AND SUCH USE IS FOR THE WITH THE ZONING DETERMINATION OF ZONING BYLAWS OF NORTH ANDOVER CONFORMITY OR NON -CONFORMITY WHEN BUILT WHEN CONSTRUCTED. P 4 ✓fie �O"v»�+rea�z a� ir�crvaa�,/,uaelta 1 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR i Number. CS 009544 Birthdate: 03/30/1948 Expires: 03/30/2002 Tr. no: 19008 Restricted To: 00 STEPHEN C BREEN 345 STEVENS N ANDOVER, MA 01845 Administrator m m m m m 0 v. d C •C Chi CACD n n Z CA CDCL o � � c CZ �• CO) � o � CD CD o CL C � cr C ? CD Er --•� CD O CD 00 Co S. C CD CA CD d O CA O I CO) CD �C Z O � CD O G CD 0 b CCi) n O Cn i� 7 I I C ��O D1 S • y O Q N S O C m= y m C m C7 O H C7 n n m m -40 O N O 0 Z�•n O Nm• W a a o g S nr,C. O N CD O CD co) CL Q' � ♦ •-► N O � y N o CO � n W N O c < : ca c m CO)o � o m � . m ,N—► co O m : O O Com:; CO O CAO o k g m .Q CD CD o N d ..w • O o_ m m : c o moo: C, o CD 0 O 0 m 0 C 5 m m C CO) H cn � p ~ Cl ?? z ?? CD ►'� 0 C~ -rl n 0 -n 0 In w a o a d z 0 Co r h y 0 9 0 c "0147 filphonse Didell q1 Heath Rd. APPLICATION FOR SEWAGE DISPCSAL IMULIATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Heath Rd. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of _750 gal* in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 180 lineal (gVM) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/$" to 1/41 (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DA TE,.�.�_ 1►; y o Sig t e of A-pplicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE /0 // C% SiOhature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Percolation Test 5 min. Soil sandy -clay Garbage Grinder Div May 28, 1960 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of seviage on the proposed Heath Road building site of Alphonse Didell. The land in general is high. The subsoil in the area was of sandy clay content and a 5 -minute percolation test was conducted.' It is recommended that a 750 gallon concrete septic tank be installed together with 180 lineal fe6t of drain pipe. Very truly yours, William J. scop WJD:hd so--•� N o ,'-) ltd D BOARD OF HEALTH TOWN OF NOlUll ANDO'CER.. MASS. MEIi, IJf- 17 1 NAME �D l(J1 E / L L . . . . DATE . .... ....,�........�` ........... 2. ADDRESS ! f.�7! . .' 1.� LOT NO. TEL. . 3. NO. OF BEDROOPIS DEN YES . . NO. 4. GARBAGE GRINDER YES . . . . NO. . 5. SHOW DII+,ENSIONS OF HOUSE 19� '4�1 b. SHOW DISTAI+ICES OF HOUSE TO ALL PROPERTY LINES �I. SHOW DII:ENSIONS OF LOT S. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL ---Tr' `:A 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM ho w 10. SHGW LOCATION OF BROOKS , STREAIV,S p DITCHES,, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULAT INS SHOULD BE READ CAREFULLY.