Loading...
HomeMy WebLinkAboutMiscellaneous - 91 WEYLAND CIRCLE 4/30/2018a y. fi1pRTH , 04��4ao �s'�Fa4 , NORTH AND OVER RUII,DING DER. .'�`IiENT ��SSACfitl ��� 1600 Osgood. Street , North Andover Td- 979-698-9545 . . Fax 979.688-9542 OgZf- DATE: 2 /c 044 NAM Woier-'6P, 444 DI,61'11 7kx1-0 c.4/r cz� r TM OF )BUSINEBR., DTMDWGLAY0T3T??R0V) DED. - YES Wo AV.AFLAB.DEP1 RIM SPACES: ZONMOBYLAWMAGE: 'SAES N� rTmcrkm SIGNA.TUO ETIM S S FORM FOR TOWN CLRRC Z40 Rome Occupation (1989132) An accessory use conducted w1bia a dwellitlg by a resident who resides in. the dwelling as his principal address-which is clearly seconda y to the useof the buck n� for filritg pluposes, Nome accapations shall 'include, "but Plot limited to the following rises; I personal services such as funned kit an artist or instmotor, but not occupWon involved with. motor Yehiple repairs, beauiy parlors, aminal kame1g, ox 1110 conduct of retail business, ordienmufacturi6g ofgoods, xvb!'CRimpacts thexesidmtialnatuxo of thomighborhood, 4. For use of a clw&iftg is any resideni d district or m0fi-ffi* distdot for a home occupa&n, the following coodWom shalt apply. a. Not more than a total of 4w (a) people may be, employed in fho,lbme occupation, ono of ivhomshall beilieo�i0rofihehome occu�aaiioxrandreschngzui;aldrfl�leifing; b. The use is carried on: siriotlsr withinfho principal building o. 'Dere shah, be no crWilor alterations, accessary buildings, or display which aro. not oustomaryr with resider U buildings, - d. Not more, tlm twmty f4re (25) percent of the exis6ag gross :Floor area of the divolft unit . so used, not to exceed one thousand (1.000) square feel, is devoted to'such. use. In. conllectron:t�riilz ', such use, there, is to be kept no stock in trade, cota od ties or products which occupy space beyond Mese limits; .e. nerevAbeno display o£gogds or waves-visible fronx the sue€i; fThe building or premaes occupied. shall not be rendered objeoiionabl'e or deirimeutai io the resi&Wax character of the, ne&orhood duo to tho oxtedor appearance, Gmissioli of odor, gas, smoke, - crust, noise; disturbance, of in any offher way become objecianable or ' dementa:[toanyresideniialusew t eneghboxhood, ,X An ch building shall include :no Features ox desir— not custornary in buildings for resldenial s North Andover MIMAP February 5, 2016 65 0-0064 065;0-0021 I 065.0-0302 065.0-0242 065.0-0243 77'WEYLAND' IR 65.0-0301 85 WEYLAND CIR 1 1�A, MI6 yI / 65 WEYLAND CER R2 065.0-0244 � *��' 065,0-0241 / 91 WEYLAND CIR,,d" �' ---- —f 88 WEYLAND CIR 065.0.0264 99 WEYLAND CSR I 065,0-0245 j 65 WEYLAND CIR i f 065.0-0255 06 WEYLAND CIR J 54 WEYLAND CIR 105 WEYLAND C11 065.0-0263 •� 065.0-0245 065.0-0266 065 I9-0024 065.0-0262 115 WEYLAND CIR 120 WEYLAND CIR 065.0-31247 06.5.0-026 i t 065.0-0261 121 WEYLAND CIR �` 065.0=0296 sr�, 065.0-0248 130 WEYLAND IR p 0 r 06.0-il298 065.0-0250 r 0 5.0-0249 * ` 129 WEYLAND�CIR, 140 WEYLAND CIR 13 MVPC Be Zoning Overlay Zoning Municipal Boundary © Adult Entertainment Distdc ' Busine s 1 District Machine Shop Village Ove Rail Line ® Watershed Protection Dist 13 Busine s 2 District O Busine s 3 Dt rict Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Interstates © Historic Mill Area 0 Busine s 4 District pORji� Valley Planning Commission (MVPC) using data provided by the Town of _ I Medical Marijuana Overlay District 0Genera Business District 0 Planne Commercial Dev Of."Oo �• North Andover. Additional data provided by the Executive Office of — SR Downtown QI Historic District C Corrido Development Dist r • 3 • Environmental Affairs/MassGIS. The information depicted on this map is for It be for legal boundary - Roads U Osgood Smart Growth (40 r Easements i. Hydrographic Features 0 Corrido Development Dist 0 Corrido Development Dist O -- - " f �' planning purposes only. may not adequate definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING Induslri 1 District ; THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY ❑ Parcels - Streams Induslri 12 DisMct _ i, _ .. ; OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT -.- Wetlands 13 Induslri '13 DistrictS District 0 lri I Indus µ o• i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF L' Exempt Lands Reside ce 1 DisMct �7 -f. THIS INFORMATION ' Reside ce 2 District C Raslde ce 3 District dei ce 4 District 1" = 128 ft=de ce s District de ce 6 District ���age esidential District -4QPP" // r This certifies that ....a p? ` /�' N'!!ti! a' ........... has permission for gas ins allation ... C �U� �5�`z,,i , , , , , , , , , in the buildings of ..^ at .... q1..�! P V.�J . , , North Andover, Mass. 2 av / Fee.,5 ..... Lic. No. �-�3. ..-'................. ... .. GASINSPECTOR Check # 07/� €619 r G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT # JOBSITE ADDRESS Q OWNER'S NAME %�► ' �p N OWNER ADDRESS TE - AX OCCUPANCY TYPE NEW:O RENOVATION: APPLIANCES 1 FLOORS - BOILER BOOSTER BURNER COOK STOVE DIRECT VENT DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER BSM 1 1 CIALM EDUCATIONAL 0 RESIDENTIAL[' REPLACEMENT: 931,00 PLANS SUBMITTED: YESE] NO[3 2 L 3 1 =I.L 5 L. 6 7 1 8 9 10 11 1 12 1 13 14 INSURANCE COVERAGE I have a current Iiabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES j["NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 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. (Y) SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Q AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are a and accurate t e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit IIP ent provision of e Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME AAoivL~ /A LICENSE # IV ATURE MP [0MMGF F-1 JP JGF ❑ LPGI [] CORPORATION D# PARTNERSHIP [:]# LLC Q# COMPANY NAME. DDRESS CITY a STATE ZIP TEL �a 7—jC�'� FAX CELL EMAIL► _fjMd Q nor m— i�lM/'/1 _ h o vo v ti V 7 tt )v)v.mass.guv%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ., Pleasc Print Lesribb Name (Business organ:vtltior, ind:\;Ju:tli:J6_6 riAiA% mn-•v?) P+ g =M Address: City/Statel1_ip:��� Q _ U tine jk _Pf 3 0 6`160" Are you an employer? Check the appropriate box: The Commonwealth of.11assachus•etts G Department of Industrial.-tccidents ML t i Office of Investigations listed on the attached sheat. - I 600 Washington Street Boston, .IL4 02111 V 7 tt )v)v.mass.guv%dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ., Pleasc Print Lesribb Name (Business organ:vtltior, ind:\;Ju:tli:J6_6 riAiA% mn-•v?) P+ g =M Address: City/Statel1_ip:��� Q _ U tine jk _Pf 3 0 6`160" Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with — _ 4. ^ 1 am a_,:; rai cun:r3u;, r and I employees (full and or part-time).* have hired the stab -contractors ' 3. ❑ 1 am a sole proprietor or partner- listed on the attached sheat. - I ship and have no employers These sao-conirac:urs hay e ! working for the in any capacity, lrke-' comp. insurance. I [No workers' camp. insurance c arc a corpura:ior, an.i its required.] officers have exerciscta their 3. ❑ 1 am a honvowner doing all %� ork righ: of exemption per %JC, myself. [No workers' sump. C. 15�. ;1, 3 . an,: �kc nave no insurance required.] " eniplo�ces. INo %+orker,' I I comp. insurance rjqui%j.] I *Any appWant that chccks box F;1 n1u,t ala,) till out the .cct • • xl , r Type of project (required): 6, ❑ New construction ?. ❑ Remodeling S. ❑ Demolition �, ❑ Building addition 1 U. ❑ Electrical repairs or additions 117 Plumbing repairs or additions 12.7 Roof repairs 13--r]Other J \ , . ,rnp,:nbj::on p,,t;c\ i.liu .,ati,11. f Homeowners %%ho suhnut this ariidavit Ind;canng dw% ;,rc: ,.,,;n a;; u„re ; ¢a r „ �,,•�.. nuaaura muse ,admit a nr\, aRidal'it indicating such, :Cuntracturs that check this hog moat attached an adcltnatal , e ; ah�,\In_ ;a: nam: ; i tr aan-:or,tract •r. altd their u„rkers' comp policy infuriation. 1 am an einploy'er that is protdding workers•' eo»rpensution in.curanc•e for tett• emplucees. Below is the policy and job site information. Insurance Company Name: Policy a or Self -itis. I.ic. ” _ -- - - — - — - -- — — C.w'ration Date: --- --- Job Site Address: Citi State Li - --- ------ Attach a copy of the workers' compensation policy declaration page (showing the police number and expiration date). Failure to secure coverageas required under Secti,,r, 2;A of.\16L c..21 ca:: lead to the imposition ofcriminal penalties of I= up to S 1,500.00 and or one-year imprisonincw. as \veil as c:% is re;ia;uca :11, the form of a STOP WORK ORDER and a tine of up to S250.00 a day against thu \ iolator. Be a\iN i5,d that a copy s:atement inay be forwarded to the Office of Investigations of the DlA for insurance coenv,c .eriricauor.. . uu hereb5l verzXv tatuer are pains utrd wultie► of perju 1/tut the infurmutiutt prat—/flea ubu a is true and correct Si nature: - Date: /� I A AL. / ..- Official ase only Do nut 1,'r/te ire tlns crrc�u, n, nccurnpldte J ht cin ur ruKvr c ffrcral. City or Town: Permit.'License P Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cit}, -loan Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: ~ .^ COMMONWEALTH OF MASSACHUSETTS SED PLUMB�illt LICEN AS A MASTER IS -,,UES THE ABO%ft- LICENSE ROBERT A SA14MATARO 8 DUNRAVGN RD WINDHAM NH 03087-1263 9333 05/01/14 170 5 COMMONWEALTH OF MASSACHUSETTS REGISTERED AS A PLUMBING CORP ISSUES I HE ABOVE LICENSE TO. NC ' WlNDHAM NH 03087-1263 > 3373 05/01/14 140820 m m ° 09841 Date. . . nsa�Y;rnJ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... +'1. !• ?.P. lz'.. ; A ;nor ch !'a....... . has permission to perform! `?. SQ �2................ plumbing in the buildings of. ..................... at ........I . F... ( Q:�. �(! ?. c� 4.... , North Andover, Mass. Fee 30,.�).L� . Lic. No... .................. ... PLUMBING INSPECTOR Check 4 1 Z l kp 9 P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # JOBSITE ADDRESS MIA OWNER'S NAME OWNER ADDRESS �Y TAX'1 OCCUPANCY TYPE COMMERCIAL _ EDUCATIONAL RESIDENTIAL NEW: — RENOVATION: _ REPLACEMENT: FIXTURES Z FLOOR BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SERVICE / MOP SINK PLANS SUBMITTED: YES !,_ NOI mmm® w •��•r+�•v� vvvertNut: ave a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES i NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ! _ AGENT _F_' I hereby certify that all of the details and information I have submitted or entered regarding this applica9E4&NA=TURE t of my knowledge \ and that all plumbing work and installations performed under the permit issued for this application will rovisio f the Massachusetts State PI ing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # MP � JP � CORPORATION 0#=PARTNERSHIP # LLC `—# COMPANYNAM ,ADDRESS CITY�� � { Q.tyiVl STATE 1�! _Y_.ZIP d TEL Q FAX CELL �EMft , sPA Vnn n ✓1nrlD r n 1..., .� .� .. 47 r a, ON ,, The Commonwealth of.11assachusetts Department of Industrial Accidents t , It ' M, Office of Investigations 600 Washington Street Boston, JL4 N 111 1t.'tt,•K',n1ass.guv1dia Workers' Compensation Insurance Affidavit: BuildersiContractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name iBusincss organwatton Indt%illlalI' Q be� � Addross:_.. L� - — City/Statel1_ip:_ji�dh a 0 tin. -. Arc you an employer? Check the appropriate box: 1. ❑ 1 am a employer with _ _ 4.7 1 am a _e::crai can;rac:or and 1 employees (full and,or part-tilne).' have hir:c the suo-contractors 3. ❑ 1 ant a sole proprietor or partner- listed on the anacned sheet. = ship and have no employees These s.to-,;ontrac:ors ha%e working for me in any capacity. �Vorke-.' comp. inst:rance. [No workers' comp. insurance `• lywe are a corporaJort an,l its required.] officers have exerci:,ea their 3. ❑ 1 am a hontcuwner doing all work r igh: of 'exemption }ger MCI myself. [No workers' cutrtr, 1 c. 15'. ; i 1 1. an: stir r;avc nu insurance req uired.I en.iplo%c�-s. I,No %+orkeri' ' 1 comp. insurance reguir,:J.I 1 Type of project (required): 6. ❑New construction ?. ❑ Remodeling S. ❑ Demolition ! 9• ❑ Building addition 1 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ',Any applicant that checks hnx p nw,t a;bo till out the soct.• A,d�;r,• , m as , n ,I:ey tnlorn;auon. t Homeowners illho submit this atiida� tt tnd:caung dwi, ;ire ...•;n_ a:; N„rj, :;,a 1_,l e.:; - �rraC:era tnusr ,uamit a rte« affidavit indicating such, :Contractors that check the hoe mea attached an adatior.a, <hc.: :aa ram; ; f;re ,un-aomract„r, and their %wrken' comp policy information. I ant an employer that is pro vidiog workers' c'ontpensution insurance for m►' emplut•ees. Below is the policy and job site information. Insurance Company Nantc: Policy 4 or Self -itis. l.ic. ” _ -- - Lxpiradon Date: --- --- Job Site :Address: Cin State lip' - -- ---4 — — -- — Attach a copy of the workers' compensation policy declaration pact (showing the policy number and expiration date). Failure to secure coverage as rccluired under Section 25A of MJ,JL c.. ca:: !ead to the imposition of criminal penalties of a tine up to 51,500.00 and, or one-year imprisonn;ent. a, x�eii a; c:t is f.c:; t ::, the torn of a STOP of ri K ORDER and a tine of up to S350AU a day against the iolaatr. Aa a,t\ isdd that a copy of :cis s:atement mai' be forwarded to the Office of Investigations ofthe DlA for insurance cm cr ue lerticauor,. I du hereby ce ' y under the pains and "IM ill of p4 that the information prutided ilii 'e is true and currecl. / Si nature: /� Date: ` ` Phony 0,?- z Official use onty. Do not Write in this area, to he completed ht• citt' or tuKvr c(ficial. City or Town: Perm iCLicense It Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, Cif�r'I own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: COMMONWEALTH OI" MASSACHUSETTS i PLUMBERS AND GASPITTERS LICENSED AS A MASTER PLUMB'ilft ISSi)ES THE A6OVt LICENSE TO ROBERT A SAMMATARO 8 DUNRAVEN RD WINDHAM NH 03087-1263 9333 05/01/14 170 S COM ,MI ONWEALTH OF MASSACHUSETTS REGISTERED ASA PLUMBING CORP ISSUES IHE ABOVE LICENSE T0: ROBERT A SAMMATARO I' ROBERT A SAMMATARD PBH, INC 8 DUNRAVEN RD' WINDHAM NH 03087-1263 t 3373 05101/14 140820 v This certifies that has permission for gas installation. in the buildings of ... , , , . at ..... .. 1,�, ^ ��} A. (I -.I ,,l .Z.- ... , North Andover, Mass. Fee �_�`��._ .. Lie. No. Ct33 ... H �................. ... GASINSPECTOR Check #_ 12 It V 8618 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE PERMIT # JOBSITE ADDRESS G OWNER ADDRESS OWNER'S NAME l�r'✓�C� �V !/Il TYPE OR OCCUPANCY TYPE COMMERCIAL❑ T AX PSTEDUCATIONAL RESIDENTIALZ CLEARLY NEW. a RENOVATION: Q REPLACEMENT: golfee PLANS SUBMITTED: YES® NOQ APPLIANCES 1 FLOORS --i, BsM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER __.. CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT UNIT HEATER UNVENTED ROOM HEATER WATER HEATER GE I have a current liabili insurance policy or its substantial equivalent ent whicNCE OhVme is he requirements of MGL. Ch.142 YES U'NO Q I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M^ OTHER TYPE INDEMNITY ❑ 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER Q AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit a and accurate t knowledge e best of my ant provision e Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. IIP of PLUMBER-GASFITTER NAME LICENSE # ATURE MP EZ'*MGF © JP ❑ JGF F� LPGI ® CORPORATION D/# = PARTNERSHIP ❑# LLC # COMPANY NAME. ¢' `ADDRESS CITY apK STATE ZIP 2=TEL FAX_j CELL EMAIL, �Si1 m/ 5 rn r% ev r--n/M e n .n e .. ` r 9 I V I I I \Y `, ^ .� �� • Qt� ; The Commonwealth of Alassachusetts (Department of Industrial.-tccidents have hired the sub -contractors Office of Investigations o.; } 600 if•ashington Street \ tit, /' Boston, .1L4 02111 - www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers i anie (Business'Organwation 1ndMdual): Address: �/ham, vCity/State/lip: 1,0 x`93 -a 6r 6 Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4• LJ I am a _eneral contractor and 1 — _ _ - employees (full and or part-time).* have hired the sub -contractors 3. ❑ 1 am a sole proprietor or partner- listed on the attached shut. ship and have no employees These sub -contractors hay e working for me in any capacity, rkers' comp. insurance. (No workers' comp. insurance e are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing al I \k ork right of exemption per MGL myself. [No workers' cutup. c. 15". § I (-t), and we have no insurance required.] eniplo\ces. [No �%orkers' comp. insurance required.] L. Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition n. ❑ Building addition 10.0 Electrical repairs or additions i I.❑ Plumbing repairs or additions 12.7 Roof repairs 13.7 Other_ 'Any applicant that checks box n l must aiso IIII uul the secu.m oclu.s showng their u,,rkcrs' ,omp,:nsanun {xilw) mtarmation. t Homeowners eho subnut this affidavit tt indicating th.y are Joon_ a:l u.)rk ;.r ,; teen ntr: out�:de .oituacturb must submit a nc\t of idavit indicating such. Contractors that check this box must attached an advitional sheet shoo tng the name of the bub -contractors and their skorken' comp policy infbrmation. I am an einplej,er that is providing workers' compensation insurance for tut,' employees. Below is the policy and job site information. Insurance Company Name:_ Pulic} 4 or Self -ins. Lic. _ Lxpiration Date:_ ____ Job Site :'Address: Cin. State 7_iP:_ . ._ Attach a copy of the workers' compensation policy declaration page (showing the police number and expiration date). Failure to secure coverage as required under Section 25A of MCI c.:5? can lead to the imposition of criminal penalties of a I= up to $1,500.00 and, or one -Fear imprisonment. as %+ell as civil penaltic., in the form of.-. STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Be adN ised that a copy of tl:iz- statement inav be forwarded to the Office of Investigations of the DIA for insurance cover:t_re �eritication. I do lrerebjce ' y under the pains and "nuhie-► of perju that the information provider! abo •e is true and correct. Si rnature:14. /3 Date: Official use ally. Do not it -rite in this area, to he completed br c•itt' or town official. City or Town: Permit;License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/To«n Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVC I.ICENISE TO ROBERT A SAMMATARO 8 DUNRAVEN RD WINDHAM NH 03087-1263 9333 05/01/14 170 tki� a[x T �:��:tca4�rlt*�'t••7�a=: 11� �,C*] COMMONWEALTH OF MASSACHUSETTS 4 REGISTERED AS A PLUMBING CURB ISSUES THE ABOVE LICEMSE TO ROBERT A SAMMATARO ROBERT A SAMMATARD PBH: INCY 8 DUNRAVEN 'RD � WINDHAM N4i 03087-1263 3.373 05/01/14 140820 Location No. , Date C H TOWN OF NORTH ANDOVER& Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ 8 M Sewer Connection Fee $ Water Connection Fee $ TOTAL i uilding Inspector i�- 9587 Div. Public Works PErAllT NCI. Z APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 MA R&e ZONE I LOT NO. IQ SUB DIV. LOT NO. 2 RECORD OF OWNERSHIP "DATE BOOK "PAGE — LOCATION PURPOSE OF BUILDING _ 1 Li! S� S-w...w OWNER'S NAME "� NO. OF STORIES SIZE J OWNER'S ADDRESS VrlJIk sL BASEMENT OR SLAB ARCHITECT'S NAME /1/I Com11 `l SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME �Tr•P ' 1 -� SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR " " GIRDERS .AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS eSEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED SIGNATURE OF OWNER OR AUTHORIZED Falllzlll;� PERMIT GRANTED 19_ I 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST ` , EST. BLDG. COST PER/ SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY OWNER TEL. # Q �T-- 1 La CONTR. TEL. # 6�-�1a8' CONTR. LIC.# o�a3o9 H.I.C. # %059'31 BUILDIN-G RECORD 1 OCCUPANCY 12 SINGLE FAMILY RIES- ' MULTI. FAMILY rOFCFCES APARTMENTS _ CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE PINE d 1 2 13 CONCRETE BIL K. BRICK OR STONE _ _ PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'T' AREA _ V, 1/2 1/1 FIN. ATTIC AREA _ N_O B M FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 'K 1 JL 2 3 _ _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING HARD"J'D COMIACN ASPH. TILE VERT. SIDING STUCCO ON MASONRY _ STUCCO ON FRAME _ BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR _ CONC. OR CINDER BLK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I -A POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I HIP BATH (3 FIX.) 4 - GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING WOOD JOIST 11 HEATING PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL 8'M'T 12ndI ELECTRIC THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 1st 3rd NO HEATING 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***************** PLICANT: / Phone 0 LOCATION: Assessor's Map Number a10 ,�5 _ Parcel Subdivision_ L ,Q Lot (s) Street St. Numb r ************************Official Use Only***** RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Public Works - sewer/water connections Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected - drive ay,,permi ire Department Received by Building Inspector Date s)e-5 '-2- 11 x P, x Q x w A u T v o y z Z i.r O cz W o G Z Z :Ea z z U u w Z :m •~o N a w ;mom c c o a w _ L = z m N a � O m > v cn a w c •_. a a O o E 2 .V d O : ev eo CD c :Ea in) :m •~o ;mom o a m 3 N N C m N � O m c •_. zipO O Ju O 0 Wdlo CO O E L O CO O O zn. O y o � co am c W C 'Q 0 •w CoE CD O O CL ~ *.+ co O i O d m O CL y � O Cd • v J •O z� V 0 CLy O C H D ' m c m 3 N C m N � C � zipO a U. O a=o cm mo.� m V H Z ' eo c N CL 2 m p N 1-- O 1--' m N m_ •O. L •N O H C.L O Z LLJ V C vi Gp� C m � �_ d � _ A O y 'O O Ju O 0 Wdlo CO O E L O CO O O zn. O y o � co am c W C 'Q 0 •w CoE CD O O CL ~ *.+ co O i O d m O CL y � O Cd • v J •O z� V 0 CLy O C H D Location No. C.-- Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ �-- ,Clt-hef Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Fs� ding inspector 196 12.47 25.00 PAID 9 517 Div. Public Works Location No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Co t' F $ 1 Z-1 L nnec Ion ee TOTAL ZT U 4 {j J��1/' 13:40 -.r Building Inspector 1,272.00 RAID Div. Public Works Location, `r;� 1zW l No. t Date 130— S Is TOWN OF NORTH ANDOVER . A Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ AlU 16?/� Sewer Connection Fee $ /Otn (9-5� Water Connection Fee $ /077, 57ZIW TOTAL Is � ildi gIn H ctd- 8995 1,000.00 PAID / / R _ v Div. ulAc Works Location C ( Ct 0 No. 10 d(o Date nvua�i vva.vuNain,Y � a.w # Building/Frame Permit Fee $ �,SSA�MUs t� Foundation Permit Fee $ Other Permit Fee $ y Sewer Connection Fee $ ' ° Water Connection Fee $ w z• ' _ ' TOTAL 6)2 _�--- Building Inspector 411/30/414-% 150.00 PAID 1 .- Div. Public Works PERMIT NO. te, APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. ZONJE LOT NO. /-� I SUB DIV. LOT NO. 2 RECORD OF OWNERSHIP IDATE I BOOK .'PAGE LOCATION %/f1� ,% �f� PURPOSE OF BUILDING !�`r.1 t es ✓ t� OWNER'S NAME.✓�U xw� �'f�C� �l J� �t�— i L?� �n NO. OF STORIES �- SIZE C CWNER'S ADDRESS 73 f BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST .2No 2ND 2 y )O 3RD ^/ BUILDER'S NAME 4" l�J� �It l f SPAN L.=— ✓ DISTANCE TO NEAREST BUILDING i4 O DIMENSIONS OF SILLS -�,` �� --_ DISTANCE FROM STREET 215- POSTS DISTANCE FROM LOT LINES -SIDES �� REAR 7 '• " GIRDERS 4 K / --- AREA OF LOT �/ •� 9 Z FRONTAGE 7,S-� HEIGHT OF FOUNDATION cj THICKNESS 16 I/ IS BUILDING NEW ®/�C JJff .•7/ SIZE OF FOOTING ���I X IS BUILDING ADDITION MATERIAL OF CHIMNEY xx 0-4V IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND v WILL BUILDING CONFORM TO REQUIREMENTS OF CODE C7 IS BUILDING CONNECTED TO TOWN WATER Y -es lyes BOARD OF APPEALS ACTION. IF ANY ,S/ IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE .QS INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PERMIT FOR FOUNDATION ONLY REGULATED BY PARA. 114.8-S. B.C. 3 PROPERTY INFORMATION LAND COST 76`b0o EST. BLDG. COST 0� Zt l `cyzx�l EST. BLDG. COST PER SQ. FT. S -z> PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM FEE PAID �d0 SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDINGDATE sla- 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS-� PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED - SIGNATOR OF OWNER OR AUTHORIZED FEE 1 3-12 — PERMIT FOR FliAMtieUit G PERMIT GRANTED Sb .LZ*FEE PAID- LM ��. Z4 I9q� DATE: No 2 G i'' a& OMIT FE t3�lZ-� KESS fm L — BUILDING OWNER TEL.# 697-//2-9 CONTR. TEL. # 7 //45 CONTR. LIC.# H.I.C. # fts�----4 CkatZ c(ft� � .0 a i&3 �*b I tiZ, -& v1 u6 BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES . MULTI. FAMILY OFFICES APARTMENTS _ I CONSTRUCTION. •. -• 2 FOUNDATION 8 INTERIORFINISH CONCRETE PINE d 1 2 I3_. CONCRETE BL'K. BRICK OR STONE PIERS PLASTER DRY WAIL _ _ UNFIN. 3 BASEMENT AREA FULL I FIN. B M'T AREA 1/1 IN. ATTIC AREA _ NO B M T FIRE PLACES HEAD ROOM MODERN KITCHEN T 4 WALLS 11,9 FLOORS CLAPBOARDS B 1 2 _ 3 _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING HARD"J'D COMMON ASPH. TILE VERT. SIDING STUCCO ON MASONRY _ STUCCO ON FRAME -• BRICK ON MASONRY BRICK ON FRAME ATTIC STIRS. 8 FLOOR I_ CONC. OR CINDER BILK. WIRING STONE ON MASONRY STONE ON -FRAME SUPERIOR I I POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.) GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET ASPHALT SHINGLES LAVATORY _ WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR _ TILE DADO 6 FRAMING 11 HEATING WOOD JOIST PIPELESS FURNACE _ FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS GAS 7 NO. OF ROOMS OIL ELECTRIC NO HEATING B'M'T 2nd _ 3rd THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES, GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. -!p ' :n !) tam �,�. �•-.: � i,� � �f`� T 1i0. a. N9 C3 U t W w z o vPQ o z A s z �O> b w CO aG cn o a o a m r. a �o o o G �" = m O U W W �%.X o v a`°U y o W 2 Q o w c4 u. a: cn ii.cq cn C/)— n CU z '? moovi o z o0 pc c�2 c � C3 v� co m C C A� O_ c LU CD G.` D � : 3 a. N Li O m ^�•�: V O m C E C Z N N N cm m N J: C m zip _ � N LKI O Ecmm N L 7 m zr o � cm C3 acs � o m ` CC -2139 o.2 39o m m //���; N O C C = o V,! a o N r N O ~ m L LU C 4 ~ -w .� c N dL = Z CC V V N O cm y O' m 'O O S eNv apL-� C C�wm F. 0 w a O 'O a ri a� 0 C • L O O co Z Q, O CO) D c O cm C O caLA 'D ECD Q CD m m co O i CO O � O L O O Q o- cma ca o Cc cv Cc v J� O •CA Z s CD CD CL V V! R C C•— cc _O) c (A 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: ox W a� 1C a,1 ✓�/ atu2 Phone LOCATION: Assessor's Map Number Parcel Subdivision _7- y ,X 1,J d a d Lot (s ) Street 14 /&14 d l /�rG�2 St. Number Use Only************************ RECOMMENDATIONS OF TOWN AG S: /-",/ Date Approved Conservation Conservation Administrator Date Rejected Comments 11i`�, 11' Date Approved J.],12-11 _ Town Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected Date Approved ptic Inspector -Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Retc e i. ilding I y I 1 i9 Z j 79G*J� N ` 2D N � --------- ---------- o -o T lc�L.441 TD T.NE B.4.vr T.S4gT T,vE OwELL/•us /S LOCATED O.v Tf/E GOT qS S/,E�i1✓.V ANO Tf/,gT/T OG+ES JO.1/FO.PiY1 /N iY'iTf1 T//ET'o .t. �✓ OF.vO ,ovoo ✓ � ZON/.vG .eEGvG,ar/ovS .r FU�TS/C P CEPT/FY T/f ECL/N6 /S NOT 4/14-4TE0 IAA T//E FEO ,�O O AZAPO QPE4, O,PAi1�/V FQ,P ,SiryOwA! Opt/ FEMA � T P,w,i/GL '� 9B o0o G- e- 9j ST v i4Pf m 76 �f L /4j LAND �fE,P,PjylgGf-,�,GivEE,Piv6 SEPv/CES LAND 5U G�-4.P,{� ,STPEET � A.r/00l�E.P, �,4SS,gE,�USETTS oi8i0 -:s KAREN H.P. NELSON Dinvor _ _-.- �� NORTH ANDOVER KILDING ��;' .•'. CONSERVATION DWMOY of HEALTPLANNING PL:\N�iNc; PLANNING & CONBIUNITY DEVELOPMENT DATE CHIMNEY APPLICATION AND PERMIT LOCATION OWNER'S NA1,1E BUILDER'S NA MASON'S NAME MASON'S ADDR 120 Main Street. 01845 (508) 682-6483 PERMIT i�.ASOiT' S TELEPHONE MATERIAL OF CHIMiTE7 INTERIOR CHIMNEY `- el -:� <,/ EXTERIOR CHIMNE`V�l/C NUMBER Al -ID SIZE OF &LUES THICKNESS OF HEART /10 Will chimney or �o reauirements of the code and have _-ul and recu_ations 'ee- received: DATE � CO"TR. i SIGNATURE OF MASON EST. CONSTRUCTION CCS1rLON.+TyACT: PRICE C� PERidIT GRANTED ROBERT NICETTA, BUTT DIG _..5. ':'OR INSPECTED REY, ARKS FEE c^ .,rTC.{ REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREIMISES 4`i COD cz I QAj�\ rd X.4 a O O W'4 , A` w` o ., w a OGO A p O Z rJ Irl ° v U"Co t7 '� OG ° Q to u o a oI a c° w° a°G U w ��U) w°' cA CU � z °q t5o11:1 N 0 vV0¢ aou- �i,� Oma; A O m :CD o I.- W f^;.ro O. ca ..,.. : E c c L :oo m� E C1 m N J C m ' •p O � 0 E m � v m Ca CD CD t t O Qf c CO a QCT p V N O ' � Z Of ; CL O Q m / =CD m C •C o = W .a �.. o Z y.., C +' P. , •ca d t O.C Z Ml C "E E � c N o C.3 CD p m C VD O_ (D O S cyo 'a C) y 0 G o. m �• 0 co L O � v O O Z O. O CO) co D � C C y p 'O co LA �E m m O � � CD O Cc O d y C � O cc vCc J� D C Z CD O O. V C* c _cc �. CU oZ000 c s \Su .ac�� ea ev > c� O W ~� r C LL C. c '0O :mom o m 3ca C_ m Qf N Cc CLSCD i c oQ O_CZ CD O j: C-) > Z .: "":m0o a. m v c = o . CL !-- C N3 m WC Co LA - ca O.Z, E a ti N O i N C O A C" CD C: C" C m o` cm c c N CD O z E mC.) CA o m oomEc g 7O CL_ _ CA m •' O .— = cyv � o ca.— CD G..=... in d d GD O co O O O Z y O Q � I C C C O■� � Q •2 w E CO m CD 0 CD CD 3 -a O �O CD L Cc O d CL CMQ ca O cc C C.3 O. O C CD V H O C • C cc Q. CO) 5 i I APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY: �� liU-eV L cJ l 0_c_/ DATE REQUEST FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: R FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED. ALL WORK AND SIGN—OFFS MUST BE COMPLETED WITHIN THIS TIME FRMME. A RE—INSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED: ^NORTH_ F e o � 'qti 16 � 7`T �. O - IAIKE �. coc..ic„Ewlcx A04ATEC PPS 'C5 9SSACHUS� APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY: �� liU-eV L cJ l 0_c_/ DATE REQUEST FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: R FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED. ALL WORK AND SIGN—OFFS MUST BE COMPLETED WITHIN THIS TIME FRMME. A RE—INSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNED: Date.?-. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...................... has permission to perform ............................. plumbing in the buildings of 111 1.2/,1 f:.�... . . . . . . . . . . . . . . . . . at. . C././S..... , North Andover, Mass. Fee.7 Lic. No. .. ...... L ........ ... D -4-N I/ PLUMBING INSPECTOR Check # 5653 n.� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) _0ALj4;2 A 1,w . Mass. DateL�t�e a R 2c�,3 Permit # Building Location ! C G Owners NamelI% AtP ri;5e T% 1�1i1G �'` : Type of Occupant 5 I D E 1J T► ,n 0 New ❑ Renovation ❑ Replacement Ie" ,,Plans Submitted: Yes ❑ No ❑ FIXTURES Z N < Z Y O Z US W W �L J N -ccY V Q �_ 7 d I N 2 N Q D: D: _¢ N W Z Z z a F- J N W N N=¢ F- t� W N Y a Q m a z o W O O W a N Q Q W y O J z a O U. W Z I� F� .? O D . 3 J F- Q Y W SL v L! h- V > t_ O S eS. z V1 F Z o o w = _Z W i.. O 0 Y rn Vf Q Q O Q J J Q ¢ Z a< o< 3 Y J (D N a a J 3 Y F dl LL. (a in Q S ID O SUB—BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4THFLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing. Company Name AOt'%e-r ,jQnimATAPfQ Check one: Certificate Address �� < ? �'� !�}t W /Y1 r1n) l� ❑ Corporation I l E Ti4 o 6"N , YO A U aa ❑ Partnership Business Telephone 9Air-e/Co. Name of Licensed Plumber '&r�3Fe r ig • . 5A,mmA iregec 1, INSURANCE COVERAGE: I have a current )ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Q' No ❑ ' If you have checkedrtes, please /indicate the type coverage by checking the appropriate box. A liability insurance policy fid' Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: 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 installationspe#ormed under the permit issuaA for this application will be in compliance with all pertinent provisions of the Massachusetts State PlumVngeode and apter of the eral Laws. By L Title re of Licensed Plumber Type of License: Master g/ Journeymah ❑ APPROVED (OFFICE USE ONLY) License Number 5 z p z N .0 m 0 O 4 r z c V m a p n 4 m O z 0 m � Amo z �e o 'q z .n m o v z c 1 � -4 m O v c z r V r v_ C p 2 Z p a fm V m .r n 4 O z m O z M o z 1 -4 O v 0 V r C Z p r