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HomeMy WebLinkAboutMiscellaneous - 92 HEATH ROAD 4/30/201810336 Date .12131113 ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... k�g1r� , e- 4... � .......... . ......... has permission to perform .......... /A ............... plumbing in the bu)*Idings o ..... */ / W -�7- j f .................................................. at ............... t ........ ... tW ................................. North Andover, Mass. Fee.3p . .......... Lic. No. M ................................................................... -?, PLUMBING INSPECTOR Check "Y3 I, - ./ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # 3 JOBSITE ADDRESS OWNER'S NAME � /��O/� P..OWNER FAX E ADDRESS TEL _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ell RESIDENTIAL d PRINT CLEARLY NEW: � RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES Ell NO E] FIXTURES 1 FLOOR- BSM 1 2 3 4 5 1 6 1 7 8 9 10 11 12 1 13 14 BATHTUB I 1 _ f ► [ i I - ___J I -__-__I I f --( —I i. CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM I -_._.._.. I I ._.._.___� ___ _! ___.-..l I ____.__ ___.-_l .____-___4 I _ADEDICATED GREASE SYSTEM —( i (_--__-.! DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM I DISHWASHER I-_! ._..! _ -I DRINKING FOUNTAIN —I _I ...1 __j l FOOD DISPOSER �I FLOOR/AREA DRAIN __. __..! . - --_i.._..._ _l I __.....I - --! ---I - - f - -i - --1 1 --------i INTERCEPTOR(INTERIOR) (......_._f .f __.-....__I ( i ----__I l i __J___ -`i .__.. __I ___I (f KITCHEN SINK --1 -! - - - -( - -_ _i -- I -- ---� ..- --I --._I ..- ---I _ ----I - -' LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _.( -__-_J ......__f ! ._ . ! --.__..._I _.. ___ i TOILET URINAL ^---' - ! - -` _l - - ' i WASHING MACHINE CONNECTION I f WATER HEATER ALL TYPES C WAT'R PIPING OTHER t ' 1 4 INSURANCE COVERAGE: 0 I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ['NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY _-I BOND P OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp ' ce with all Pertinent pro ' ion o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ._. ... _._._...--...- ,_.�.. LICENSE # SIGNATURE VIP Id JP D CORPORATION . #1AM]PARTNERSHIP 0# LLC 0 #. COMPANY NAME _y�/�fB�.�6�. . DRESS CITY ZIP - _...._. _ _ -_ STATE, ZIP 1�� ) TEL _-- $ — ,3 _ ? FAX ICE LL ' EMAIL 4 o�eh _.. Iclr�f7iYJ_ Q _. _.-._ .._ .14i,(_ -W MO y ❑ w 0— ui w LL f�, r Date ... /! // 1.1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................. (� -- - ---- $-e . .......................................... has permission for gas installation .......... A..-Ily .. ............................... in the buildings of .... 40',ov ................................................................................ at ................. ......... -14.lell .............. . North Andover, Mass. Fee.2.4 ....... Lic. No. ftfp.�7 ....... M. ....................................................... GASINSPECTOR Check # 9055 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Tip 94t;Z0 CITY _ Jt/ 0�/ MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME L G. OWNER ADDRESS TEO FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL E( RESIDENTIAL CLEARLY NEW: F-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES-( NOR APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _... L ! I BOOSTER CONVERSION BURNER COOK STOVE_ I I DIRECT VENT HEATER (. = 1 I= = __j DRYER FIREPLACE FRYOLATOR FURNACE L I _ GENERATOR _ _ _(. I --I .-_ -_( _—i .�—� _— I _.._ : I __ J I�--I ---- �— -- • ! GRILLE INFRARED HEATER _ I --J . _ I___ — _ — LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM /SPACE HEATER ROOF TOP UNIT TEST-_((- _ - I UNIT HEATER _ 1-_�- .. ._h- (:I - ._. I - _- -- -- ---- — - I UNVENTED ROOM HEATER I !_._, _ 1 ._.I !_..__ [77i i_7-77. - f___f _ __.-...-1 WATER HEATER I�--11__-1 --J Ii i I_��_. I--- ! (_ �._- I _J (__i I.J LMZJ Qr ER _ _ I I. . - - I 1 _ J .� ._--�1. .... . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES _01 NO 1 IF,YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY Ej BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best ofmy knowledge the and that all plumbing work and installations performed under the permit issued for this application will be in compli ce with all Pertine t pro 'W�- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� PLUMBER-GASFITTER NAME LICENSE # 3 ( SIGNATURE MP 5J MGF 0 JP EI JGF 0 LPGI © CORPORATION [►# o?/ PARTNERSHIP# LLC#- COMPANY NAME; _ �1!%�c�.f/N �! DDRESSi�S! CITY STATE ZIPfTEL unag P99_ i • Co - __ __ FAX CELL _ _EMAIL RifC?�of�ef-v,61 0 E z N ❑ ra i The Commonwealth of Massachusetts Department of Fmdustrial Accidents Office of Invesiigations 600 Washington Street Boston, MA 02111 wwwanras&gov/dia Workers Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pring Legibiy Name (Business/o aau=anon/Inaividual): /0/V'wg<LSO'. i Address: p -1 �/7/%T/� City/State/Zip: %�%�� /�%%�" ����,l� Phone #:_ Areyou an employer? Check the appropriate boa; Type of project (required):' 1. [I am a employer with S 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 7. F❑ Remodeling 2. ❑ I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have 8. E] Demolition working for me in any capacity. inst workers' comp. insurance. 5. ❑ We -are -a corporatio4 and its 9. ❑Building addition [Na workers' comp ct; required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 1 L [jjPlumbing repairs or additions myself o workers' 3's Ll`T �• c. 15Z §I (4), and we have nn. �) 12.❑ Roofrepairs insurance required.] t employees_ [No workers' 13.❑ Other comp. insurance required.] `.may iii sir at chess box4l ruin+ also fill anithesection sho—mg Comgen..doz polis,71 info icon. T homeowners who submit this affidavit indicating they are doing aV work: and then hire outside contractors must submit a new affidavit indicating such. * Contractors that check this box must attached an additional sheet showing tike name ofthe sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insuraiice.Company Name: Policy # or Self -ins. Lic. #: Job Site Address: dlfw Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office or Investigations of the DIA for m=,ance- caverage- verification. I do hereby certify un the pains and penalties of perjury that the information provided above is true and correct - Simature: pDate: 1,21,3111S Phone #: J 4 51 0'j,'M-4d use only. Do not write in this area, ta-be-completerl by city or town Oficial City or Town: P'ermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: Information aji d Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emplo�ces. Pursuant to this statute, an employeels defined as "...every person -in the service of another under any contact ofbice,. ,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation orother legal entity, or any two or more of the foregoing engaged in a joint enterprise„ and including the legal representatives of a deceased employer, or the receiver or trustee of an iudividual, partnership, association or other legal entity, employing employees. However The owner of a dwelling house having not more $pan three apartments and who resides iimein, or.the occupant of the dwelling house of another who employs persons to do main*3+arce, construction or repair work on such dwelling house or on the grounds or budding appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,- §25C(6) also states that "every state or local licensing agency shall withhold the issuance'or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of cohatpiiance with the insurance coverage required." AdditiomMy, MGL chapter 152, MC(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pedormanee of public work until acceptable evidence of compliance wrih the insurance requirements of this chapter -have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checlou g the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liabfiity Partnerships (LLP) with no employees. other than the members or partners, are not required to carry workers' compensation insurance. If an LLC -or LLP does have employees, a policy is required. Be advised that this affidavit rrtay be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retied to the ci;y or townuaaa`s the application fix the -y--,jmit or license is being requested, a at fine Department of Industrial Accidents. Should amu have any gaesiions regardimg the law or if you are required to.obtam a wofl=' compensation policy, please call the Department at fire number listed below. Self-insured companies should enter their self-iomn-anee 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 lavestigations has to contact you regarding the applicant - Please be sure to fill in the penmittlicense number which will be -used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "a1 locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that: a valid affidavit is on file for firture 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 ventre (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit _ The Office of brmugations would like tc thpa you in advance for your cooperation and should you have. any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwe t of fas�rli>? Department: of Industrial Accidents OIRM of h wetigat iam- 600 Washington Street Boston, MA 02111 TeL # 617-727-49-00 oft 406 or 1-877 MASSAFE Revised 5-26-fl5 Fax # 617-727-7749 www.massgovfdia I '4b, z -COMMONWEALTH OF AC USE'iTS ki PLUMBERS AND GASFITtERS REGISTERED AS -A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: :5EORGE R.-LAROSE ANMVER-PLUMRING & HEATING.- .-'C- -7-2,0 AWEAN DR .-MTHUE'N. NA. 01544:-15.80 :y -5 COMMONWEALTH OF IWASSACH - 2w Rel @ mil i PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER', ISSUES THE ABOVE LICENSE TO: _GEORGE R LAROSE Me '-44 WILE ST -METHUEN MA 0 1844---:42'3-S---jt.. 9983 05/01/14 172563 .W tr 07 :OMMONWEALTR OF mAssAcH USETTs,=--;7. ftft 9 N . .M. 5— o opo PLUMBERS AND GAS FITTERS JOURNEYMAN CENSED AS A PLUM ISSUES THE ABOVE LICENSE TO. .:GEORGE R L=AROSE 44:013.11LE ST IETHUEN HA 01844-4-2331�- 18723 05/01/14 ;:7' 17ZS62 NQ -.3131 Date ..... ��Z/Z// ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ........ /� -. � �(. � ........... 7 rj, (- P has permission to perform ..... ...................................... . wiring in the building of .......... r<a 7 AA Z.// ..................... at ............. ...... ....................... North And ver,,Mass' Fee .............. . Lic. No./ ELECTRICAL IWSPECTOR .... Check # -:2S WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use Only Permit No_ r ?,�E ean�o�,zz�rf�.�T a; �ss�et�sS77s Do—&—t 4 ;I -d&: S14d# Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number Owner or Tenant 715kA t Owners Address Date G— (l 6 To the Inspector of Wires: Is this permit in conjunction with a building permit Yes ❑ No ❑ (Check Appropriate Box) (,)( Purpose of Building Utility Authorization No. Existing Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters New SerWce Amps Volts OverheaddZ Undgmd ❑ No. of Meters Number rof Feeders and Ampacity t Location and Nature of Proposed Electrical OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a cunen Liability Insurance Policy incl di glompleted Operations Coverage or its substantial equival YES NO = have ed valid proof of same to the Offlc S = NO = If you have checked YES please indicate the coverage by checking the appropriate box IN = BOND = OTHER = (PI se Specify) (Expiration Date) Es Value of lectricai Work$ Work to Start . / — Cf / Inspection Date Resquested Rough Final Signed FIRM NAME rthe Penalties of perjury: / ���� / y ` a y � LIC. NO. Bus. Tel No. Address �i�« / 7 A�� Aft Tel. No. OWNER'S INSURANCE WAIVER: 'am aware that the L tenses does not have the insurance coverage or its substantial equivalent as required by Ma husetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ v " (Signature of Owner or Agent) Total No. of Liqht8ng Outlets No. of Hot fuse No. of Transformers KVA Above ❑ In ❑ No. of Lightinq Fixtures Swimming Pool qmd ❑ gmd ❑ Generators KVA No. of Emergency lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices Heat Total Total pp No. ofA sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No. of -Dishwashers Soace/Area Heating KW Detection/Sounding Devices ❑ Municipal ❑ Other g No. of Dryers Heating Devices KW Local Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a cunen Liability Insurance Policy incl di glompleted Operations Coverage or its substantial equival YES NO = have ed valid proof of same to the Offlc S = NO = If you have checked YES please indicate the coverage by checking the appropriate box IN = BOND = OTHER = (PI se Specify) (Expiration Date) Es Value of lectricai Work$ Work to Start . / — Cf / Inspection Date Resquested Rough Final Signed FIRM NAME rthe Penalties of perjury: / ���� / y ` a y � LIC. NO. Bus. Tel No. Address �i�« / 7 A�� Aft Tel. No. OWNER'S INSURANCE WAIVER: 'am aware that the L tenses does not have the insurance coverage or its substantial equivalent as required by Ma husetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) Telephone No. PERMIT FEE $ v " (Signature of Owner or Agent) AK Date... �� .. n -/ . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ' ................. has permission for'gas installation - - :> ............ in the buildings of ........ /. ............ . at %� . f ---t'e* .�- .....�I ! , North Andover, Mass. Feed? . Lic. No,'/, i.......... y� G�iS INSPE Vt Check # �- // 4:'48 G MASSACHUSETTS UNIFORM APPLICATAON FOR' PERMIT TO DO GASFITTING tPrint or Type) J Mass. Date �0- Permit g BWlding Location ,e er owners namd--;�Z.4? _•� TypeZf Occupancyes. New Renovation D R iacem/tD Flirty Submitted: Yes D No t / 9 ,w Lu u /J c 0. 0 , , T w FO- m In I -.Lu BASEMENT 1ST OLF OR 2ND FLOOR 3RD FLOOR Installing Company Namen/,,,,,,,-. AddressCheck one: Certificate. i 2r-Eorporation/o— . Business Telephone�❑ Partnership ? . . Name of Licensed Plumber or Gas Fitter T ❑ -Firmto. INSURANCE COVERAGE! I have a cUrrenpflablllty insurance policy or Its substantial equivalent, which meets the requirements of MCL Ch 142. Yes No ❑. If you. have checked Yes, please indicate the type of coverage by checking the appropriate box. •* A liability Insurance policy Other tyoe of indemnliv C OWNER'S INSURNACE 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 onth s perm t application waives this requirement Signa re o owner or Owners Agent Check one: ' Owner D Agent ❑ I hereby certify that all of the details and Information I have submitted for enteredl in above application are true and accurate to the best of MY knowledge and that all plumbing work and installations performed under the permit Issued for s application will be in compliance vitt, all pertinent provisions of the Massachusetts State 0 a Code and Chapter 142 of the General Laws. ;41-e, of License: `� By be Tido signature of L used Plumber or Cas Fitter Cityrl own D fitter APPROVED (OFFICE USE ONLY) aster License Number D J ourneyman n I Date. .//-. o'.: •:1ti TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... --.-t ....... ............... has permission to perform ... ................... plumbing in the buildings of ... ...... . at ..�X� ...��* ..�-..... ,....... , North Andover, Mass. Fee J7,S?% . Lic. No..79Z ../ �•; G.G j.�............. PLUM89N`0INSPECTOR Check # t� 62'58 IN MASSACHUSETTS UNIFORM APPLICATION FOR.PERMIT TO DO PLUMBING (Print/or Type) / (1 �r 4 ° iydd<�fr , Mass. Date /FF7iv 20 f % Permit # Building Location ,, 1i�,i G_ a. Owner's Nae� Ty a of Occupancy New ❑ Renovation ❑ Repia e " entAp� Pians Submitted: Yes ❑ No ❑ FIXTURES B.P. # 'SEWER # Installing Company Name �,� a�C?ir! ��r<+r�..r r y- a i�, Check one: Certificate ft .v Address 0�0 &"&rporation B1f r—?9pS .Business Telephone o � � ❑ Partnership�1 Name of Licensed Plumber or Gas Fitter �//,/� ❑ Firm/Co. INSURANCE COVERAGE: I have a current ability Insurance policy or Its substantial equivalent, which meets the requirements of MGI -Ch. 142. Yes No ❑ If you have checked Yes, please Indicate the type of coverage by checking the appropriate box. A liability Insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent 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 installations performed under the permV issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 o he General LawsBy. Title Signature of Lice ns lumber Tit City/Town Type of License: C�'Master ❑Journeyman APPROVED (OFFICE USE ONLY) ���� License Number MMM MMMMM MM MM M MMM . ..• MMMMM ======= M��� ::miiiiiiiimiiiiiiiiiMii� Installing Company Name �,� a�C?ir! ��r<+r�..r r y- a i�, Check one: Certificate ft .v Address 0�0 &"&rporation B1f r—?9pS .Business Telephone o � � ❑ Partnership�1 Name of Licensed Plumber or Gas Fitter �//,/� ❑ Firm/Co. INSURANCE COVERAGE: I have a current ability Insurance policy or Its substantial equivalent, which meets the requirements of MGI -Ch. 142. Yes No ❑ If you have checked Yes, please Indicate the type of coverage by checking the appropriate box. A liability Insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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. Signature of Owner or Owner's Agent 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 installations performed under the permV issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 o he General LawsBy. Title Signature of Lice ns lumber Tit City/Town Type of License: C�'Master ❑Journeyman APPROVED (OFFICE USE ONLY) ���� License Number This certifies that has permission to perform Date/ —/ ..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING �... ..................... p U .......................................... wiring in the building of ...... ............................................... at ... ....................... . NtSiagAindover, Mass. ..... Lic. No ....... z .... ............... �ELECTRICALINSPE (�ho�L M. S/S Nl7 5526 THECOMMONWEALTHOF SACHUSETTS Office Use only DEPARTNR'NTOFPI1BLlC ETY vt Permit No. BOARDOFFIREPI'EVEIVTION UTATIONS527CMRI2.M 3�5 rrl Occupancy & Fees Checked APPUCATTONFOR PES O I, ERFORMELE=CAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH HE .ASSACHUSSTS ELECTRICAL CODE, 527 CMR 12: 00 Q (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date J Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work desc 'bed below. Location (Street & Number) -Z ,$1WO� Owner or Tenant Owner's Address !i Is this permit in conjunction with a building pe it: Yes �No r7 (Check Appropriate Box) Purpose of Building �Ui `e 1 Utility Authorization No. Existing Service Amps / Volts Overhead Underground No. of Meters New Service Amps Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work f/ e- 1 y No. of Lighting Outlets _�� No. of Hot Tubs V 4 No. of Transformers Total V11 No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners hi? of Ranges No. of Air Cond. Total I FIRE ALARMS No. of zones "A Tons No.bf Disposals No. of Heat Total Total No. of Detection and Pumps Tog 4 KW Initiating Devices No. of Dishwashers Space Area Heating NQ. p Sounding Devices ' " (U p ' ` ' N&' bf.Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local Municipal Other Connections No. of Water Heaters KW No. of No. of signs Bailasis No. Hydro Massage Tubs I No. of Motors Total HP THER• i11tZR.111; • Ir- I:q n� ua ti •,iTF'.i'•�n II • r iu- .i• r•• • �r - • I - �itr 'r� 1005, •ria ••. AtoShaft - h TectionDateReVested sthantiaalltxltli<•alatt YES NO ' mac- •: 'NER'SINSURANCEWAIVFR;Iama thattheLicensedoesnothave that my signa mon this periut application waives this mqt cement :ase check one) Owner® Agent igna ure oT Owner or Tgenf NONE= vI.I• •.r •u a r.• . i - • Cl.:•u r, r� LicawNO BusiimTel.No. ,T 7-7/ Alt Tel No. aftamaleqmvalentasopiedbyNLissaLtuse8GffrdLaws Telephone No. PERMIT FEE $ .lam The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation insurance Affidavit Name Please Print Name: Location: Citv Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone#: Insurance. Co. Policv # t Company name: Address 1. City: Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as.well_as_civil.,penattiesin-the fnrmnfa_STOP WORK ORDFR.and a.fine.of_(.$1D0.00)_atiayagainst me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date `1 Print name Phone.# y' Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Q Licensing Board F-1 Selectman's Office -Contact person: Phone #. F� Health Department ❑ Other Location No. Date 9 d NORTH TOWN OF NORTH ANDOVER S Certificate of Occupancy $ C Building/Frame /Frame Permit Fee $ s�ust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ i Check # 7656 ✓`%- Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: BuildingCommissioner for of Buildin Date SECTION 1- SITE INFORMATION 1.1 Property Address: /1 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS 00 Front Yard Side Yard Rear Yard Reauired I Provide Required I Provided Required Provided 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Zone Flood Zone Information: imide Flood Zone ❑ 1.8 Municipal Sewerage Disposal System: ❑ On Site Disposal System ❑ Public ❑ Private ❑ License Number r/ A 0 t ,v w � /� ' 4 . SECTION 2 -PROPERTY OWNERS AUTHORIZED AGENT '!'r� �! !C District YCS �,jp 2.1 Owner of Record I i/ 3.2.'Registered HomeImprovement Contractor Not Applicable ❑ Now Name (Print) Address for Service V al Owner of Record: ,'Name Print Address for Service: N 1 � a 1,r'Worlm WUUX/ri'Y'\ 1 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: 7 a License Number r/ A 0 t ,v w � /� ' 4 . Address t1; �� �(�U Expiration Date Signature Telephone I i/ 3.2.'Registered HomeImprovement Contractor Not Applicable ❑ SC;Dlnpany Name . -G-(/ Registration Number V l f— Address r ��� (, Vy e:�',aa � Expiration Date Signature Telephone 00 1 4 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 .......0 No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ ( Demolition ❑ I Other ❑ Specify Brief Description of Proposed Work: I CRC'TTnN 6 - F.CTTMeTRn rnNCTRTTrTYnN e-rerTc I Item Estimated Cost (Dollar) to be Completed by permit applicant OC{ISE on _ 1. Building / / ego 0 (a) Building Permit Fee Multi lier 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 .a.a - 1V J3Z It-WALrJu Bill wn-UN OWNERS AGENT OI -,CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/1(uthorized Agent subject property Hereby authorize � t on My behalfalf, in all matters relative to work authorized by this building permit application. Si iature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1> ,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 Print Name of Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 s 2ND 3 RD - 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 FII LED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE .-i .0 M U co I z it Ce) 0 0 �? CS C14 CUIJ 0 CL \eco z z 0 \§U C, m§ (� S 'o Z' U) a 0 Cp 0 c E CL Q coui 4, 0 3 Z ®w 'we < 022 1 \\k <E§ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print I C C 9� J C9 Location: ;&� 2� l(o ��r j �a Cid ! Ye_1 City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity 0 I am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone#' Insurance. Co. Policv # Company name: Address Clty: Phone #• Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a fine up to $1,500.00 and/or one years' imprisonment -as well_as_civil..Renaltieslnlhelbrm d-a.STOP WORK_ORDER..and..a fine..of.(.$100..00)-ajfty.agaireit.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify undV the pard penalties of perjury that the information provided above is true and correct oiynature v!yoTtDate Print name Phone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Ucensin ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone A- ❑ Health Department ❑ Other PAGE 19 _ r I_I E & S INSURANCE DATE (MMIDDnYY l '=l3i 1 :' r[1L�4 I�9: 2p 6032937188 pg/13/2004 ACORN,, CERTIFICATE OF LIABILITY INSURAINCE138UDASAMAT7EROFINFORMATION FAX (603)293-1188 THISCERTIFICA PRODUCER (603) 293-2791 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE E & S Insurance Services LLC HOLD>=R. THI8 CERTIFICATE DOES NOT AMENn, EXTEND OR 21 Meadowbrook Lane ALTER THE COVERAGE AFFORDED 6Y THE POLICIES BELOW. NAIC # P 0 Box 7425 INSURERS AFFORDING COVERAGE -.-4------ Gilford, NH 03247-7425 INSURERA: Western World insurance Co. I IHsuReo Carl Woekel &Son, Inc. IN51JRER13; 853 Ocean Boulevard INSURER C: Hampton, NH 03842-2516 INSURE.R0: INSURER E' CONTRACT OR oTr1ER DOCUMENT WITH RESPECT TO WHICHI EXCLUSION• AND AONDIT CINS of SUCH THE POLICIES OF INSURANCE LISTED BELOW HAVE ONT BEEN ISSUED TO THE INSURED NAMED ABOVE I"OR THEPOLICY PERIO'IFiCATED INDICATED. NOTWITHSTOR ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CIN IS BY THE POLICIES DESCRIBED HERE PCJIIC Es7 AIGGRTHE EGATEIJLM TS sHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS SUBJECT TO ALL THE POLICY EFKECTIVE POLICY EXPIRATION LIMITS 000' Doc SA OD' TYPE OF INSURANCE POLICY NUMBER EACH OCCURRENCE $ 1 , OFR 04/01/2004 04/01/2005 DAMAGE TORENTEO $ 50,00( GENERAL LIABILITY - — !Iv1ERc;lAL i3ENERAL LIABILITY ii X CtC MED EXP (Any one perBuiQ 5 CLAIMS MADE U OCCUR PER$UNAL B.ADV IWII%t`I i ' 1 000,00 A Lt GENERAL AOORE(3ATE h 2,000.00 PRODUCTS -COMP/OP AGr. 9 1,000,00 _ GEN'AGGREGATE LIMIT APPLIES PER: L r PRO- F7 LOC POLICY I JECT COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY (Ea accident) ANY AUTO BODILY INJURY 5 ALL I),mV ED AUTOS (Per person) SCHEDULED AUTOS - BODILY INJURY ' (a HIRED AUTOS (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE 5 (Per accidiont) I AUTO ONLY, EA ACCIDENT S ©ARAOE LIABILITY A ACC S OTHFRTHAN AIJY AUTO AUTO ONLY: ACC EACH OCCURRENCE 5 I EXCES31UMBRELLALIABILITY AGGREGATE $ OCCUR ❑ CLAIMS MADE L 3 DEDUCTIBLE $ — RETENTION 3 WC STATU- 0TH' WORKERS COMPENSATION AND E.L. EACH ACCIDENT EMPLOYERS' LIABILITY E.L. DISEASE • EA EMPLOYEE i ANY pROPRIETOR/PARTNER/EXECUTIVE . OFFICEWMEMBER EXCLUDED? E.L. DISEASE - POLICY LIMIT 5 I If Y" caPc2e Under 5,E41AL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS LOCATIONS IVFHICLE81 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS SHOULD ANY OF THE A50VE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMP08E NO OBLIGATION OR LIABILITY OF ANY KIND UPON THII INSURT8 OR REPRESEII TATIVEB, YH6RIZED REPRESENTATIVE CORPORATION 15 tnuuunQA -AOORO.M CERTIFICATE OF LIABILITY INSURANCE DATE 03/30/04D/YYYY) PRODUCER USI New England PO Box 6360 Manchester, NH 03108-6360 603 625-1100 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED John Horan Construction LLC 21 EVERGREEN DR Hampstead, NH 03841 INSURERA: Hartford Insurance Company 29424 INSURER B: Eastguard Insurance Company 14702 INSURER C: INSURER D: INSURER E: - - %1V V Cr[I1UGJ OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING THE POLICIES TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT, MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY A GENERAL LIABILITY 04SBAGQ8654 04/01/04 04/01/05 EACH OCCURRENCE $1,000,000 PREMISES (Ea occurren ',e) DAMAGE TO RENTED $300 000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) $10,000 CLAIMS MADE a OCCUR PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 POLICY PRO- JECT A AUTOMOBILE LIABILITY 04UECTU4440 12/30/03 12/30/04 COMBINED SINGLE LIMIT $500,000 (Ea accident) X ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS X HIRED AUTOS - - BODILY INJURY $ X (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGELIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ AGGREGATE $ OCCUR CLAIMS MADE $ DEDUCTIBLE $ RETENTION $ B WORKERS COMPENSATION AND JOWC419749 04/01/04 04/01/05 OTH- X WC LIMITS ER E.L. EACH ACCIDENT $100,000 EMPLOYERS' LIABILITY ANY PROP RIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $100,000 E.L. DISEASE - POLICY LIMIT $500,000 If yes, describe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Operations usual to the insured CERTIFICATE HOLDEK _ %1AMIQI.LN I KJ" Carl Woekel & Son Inc. 853 Ocean Blvd Hampton, NH 03842 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL I () DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR N TIVE ACORD 25 (2001/08) 1 of 2 #74379 BAFCA v Mt�Vrcu %.WFXF-V I rVil I- AName of Service Since 1897 CONTRACTORS AND BUILDERS 1V xgt= $txm X P 0 Box 23 16 Methuen, Massachusetts 01844 (978)682-7901 Fax (978) 688-3413 September 1, 2004 Mr. & Mrs. Thomas Lamson 92 Heath Road North Andover, MA 01845 Dear Mr. & Mrs. Lamson: I am pleased to submit the following price on work remodeling kitchen and breezeway. Kitchen: Woodmode frameless Brandywine maple wAace finish as per plan Granite, samba white, countertop with reverse bevel edge Remove existing cabinets, install new cabinets, soffit, crown molding, light rail and toe kick Install oak floor to match existing Install dishwasher, refrigerator, island panels Laundry: Remove sliding unit and wall sheathing Install new window and door unit Insulate walls and ceiling as needed Wall at end of washer and dryer '/2" drywall — walls and ceiling, window and door trim Bi -fold door unit in front of washer and dryer Install cabinets above washer Wall heater off existing boiler with thermostat Install ceramic tile floor Plumbing, electrical and painting not included in price. Jackson Price -----$43,317.75 Alterations------ 18,420.00 Total Price --------$61,737.75 Very truly yours, Carl Woekel, President The Commonwealth of Massachusetts Department of Industrial Accidents -Office of Investigations 600 Washington Street Boston, Massachusetts 02111 Affidavit of Exemption for Certain Corporate Officers or Directors Tuesday, August 17, 2004 Pursuant to the provisions of MGL 152, Section 1 (4) as the amended by Ch. 169 of the Acts of 2002 your affidavit has been reviewed and the Office of Investigations has determined the following: NOTE: It is your obligation to submit an approved affidavit to your insurance carrier in order to complete this process. [The affidavit was approved'77approved date 08/17/2004 Attached please find your approved affidavit The affidavit was rejected j rejetion cdateJ F --- - --------- - --. Your affidavit was rejected for the following reason(s): ❑ The affidavit was not signed by all Corporate Officers or Directors. We have enclosed another form please provide all signatures required and resubmit. ❑ The affidavit is not an original (THIS FORM CAN NOT BE REPRODUCED ONCE IT HAS BEEN SIGNED) ❑ Information provided does not match the Secretary of the Commonwealth Corporate records. ❑ The affidavit you submitted is an obsolete form of the Department.. We have enclosed the appropriate form. Please complete and resubmit. ❑ Corporation is not listed with the Secretary of the Commonwealth as a valid Massachusetts corporation. Other: i Carl Woekel & Son, Inc. P. O. Box 2316 Methuen, MA 01844-2316 # jInvest�igation//SWO ID # I 1 Affidavit ID # 121949 t ~ 6 FORM 153 The Commonwealth of Massachusetts APPAb iED Department of. Industrial Accidents Office of Investigations - Dept, 153 AUG 17 2004 600 Washington Street — 7th Floor, Boston, Massaehusetto 021.11 http;//www.mass,gov/dia Invest./S1vO 1.D # AFFIDAVIT OF EXEMPTION FOR CERTAIN CORPORATE OFFICERS OR DIRECTORS Chapter 169 oj'the Acts of 2002 amended M. G.L. c. 152, ,¢1(4) by adding the following paragraph: "This chapter shall be elective for an officer or director of a corporation who owns at least 25 percent of the issued and outstanding stock of the corporation; Notwithstanding section 46, these provisions shall apply only if the corporate officer provides the commissioner of industrial accidents with a written waiver of his rights under this chapter. Said commissioner shall promulgate regulations to carry out the purpose of this paragraph. Violations of this paragraph shall subject the corporation to the penalties set forth in section 25C." Pursuant to M.G.L. C. 152, § 1(4) as amended, Me the undersigned officers of. "1!b� c / ,I- Soy hG GAO, bo,K a3/&ep/i eta 0 le'41 , (Name of Corporation and Address) each holding at least 25% of the issued and outstanding stock in said corporation, do hereby invoke the right to be exempt from the provisions of M.G.L. c. 152, §25A and therefore are not required to carry a workers' compensation policy covering the undersigned corporate officer(s) or director(s). ICWe the undersigned do also waive any and all rights to make claims for benefits as defined it) M.G.L. C. 152 for any injuries that may be sustained while in the employ of the above-named corporation. Further, I/we the undersigned do understand that, should the above-named corporation hire or have in its employ any employee(s) in addition to the undersigned corporate officer(s) or director(s), said corporation is required to obtain workers' compensation coverage for the employee(s) as prescribed by M.G.L, c. 152, §25A.. I/We the tutdersigned have read and understand the statements and obligations as delineated above and UAve have checked the appropriate box below my/our name(s) indicating my/our desire to be exempt or not to be exempt froui the provisions of M.G.L. c. 152. Signed un er thepainsand penalties of perjury: �Sipnanve Print Name & Title pate (m:rrYdd/yyyy) I, w.i6b m exercise my right of exemption or [:] 1 wish NOT to exercise my right of exemption Signaaa•e Print Name & Title � Date (mm/dd/yyyy) I wish to exercise my right of exemption or 111 wish NOT to exercise my right of exemption. r.. �j Signatwe Print Name & Title pate (mm/d.cV.yyyy) I wish to exercise my right of exemption or I wish NOT to exercibe my right of exemption Signanu•e Print Name & Title Date (a4dd/yyyy� I wish to exercise my right of exemption or 1. wish NOT to exercise my right of exemption Note: AU ELIGIBLE CORPORATE OFFICERS MUST SIGN, THERE CAN BE NO MORE TRAN 4 SJGNATURES.�strue 1�ns (^�` On brrCk. Form 153. IO,h,02 UJ North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector rn 1 x u w chi a w a z a PQ a w° a°4 U C x a w � a n°' in w a w a � a W a°' '�c w UW W C20 w G W 0 z �' cn o to CO O azo Mrd^ W P-4 m LLI ul U) 19 W 0 W N c o o CCCJ C.3 a� CDm c :Z 2 �' a =0 o toy, (�! cm O c ti E hccr.. co H cm ; 3TC H C_ O C CID r: y C O cco o co A- h O m Ic 'm o e. r •: v yz m 0 CMJoao c a m � ID :0�3 S = oS~ m z = .a 'N O w 42 JD li c F- Go o� O 2 CL CO O azo Mrd^ W P-4 m LLI ul U) 19 W 0 W N Location `-7- /e,,/ No. Date TOWN OF NORTH ANDOVER A Certificate of Occupancy $ a Building/Frame Permit Fee $ �'1SSACHUSE�� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ ection Fee $ p.&jj) 13y MMIK TOTAL $ APR Building Inspector C�®. Qndod�� C®Ile¢t�®Q Div. 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Z J > Z 'a - LL¢z LL O wwIX v� m Oi p z Z� a?��oOOzzIXzz ¢ w z z Z� w U m Z x �O vi O vi iia LL Z i K w K O �Ov 0 0 00000 JIX ¢ a IX H N V V zuw OOma Y V1 . Z m 1 'a a d O= aoox N F U ��uuZOO U Y Y u Z Z N maojIX Ti�� ,y ee Jzljn �' 0 a;gni¢ F�3 n Zlw 2 IX Uo inww a a> NNmm o�ecO�� V NN Q�n� (� a QO 3 Hh-d' 3 �-N m� 0 1• COMMONWEALTH a DEPARTMENT OF PUBLIC SAFETY , w r OF 1010 COMMONWEALTH AVE. BOSTON, MASS. 02216' MASSACHUSETTS ENCLOSE CHECK OR MONEY ORDER., ,L•,.k LICENSE .. EXPIRATION DATE CONSTR. SUPERVISOR FOR REQUIRED FEE, ! 06/ 30 / 1 991EFFECTIVE GATE LIC-NO. g MADE PAYABLE TO 1 NESTRICTIONS NONE "-T3iA: "06/30/1989 002707 6 , "COMMISSIONER OF PUBLIC SAFETY" CARL W WOEKEL (DO NOT SEND CASH). 147 WASHINGTON I �. SS 0 021-24-351WA393 METHUEN MA 01844 PLEASE mft JrfE INC'RE:A�� � •�OIO IBLASTPIO'OPR ONLY) FEE: .L�i✓✓ C. 1. !I;_ ' 100. Qo,er u116 19W`4 �` � ;z1 . EFFECT-LU �elb .. HEIGHT: NOT VALID UNTIL SIGNED BY LICENSEE AND Of FICIALLY vy' TF1= DOB: STAMPED - OR SIGNATURE OF THE COMMISSIONER 07/30/1929 n �// /� / /r`�' S�?t�d D S D.P.-S' - THIS DOCUMENT MUST BF CARRIED ONANEPEMON a SIGN NAME IN FULLABOVE SIGNATUEIE LINETHE • 1 S NATURE OF NSEE �I. •MFRS RIGHT THUMB PRINT ED N HOLDERHEN ENGAG OTHISW OCCUPATIOI r}�/� MMLssaNEn �+/fu-c��`*✓�i��� ' I 1 1 3 .IL,.I,. •,:� .I, Id.1L, '..)M•2-87.81429 H C.0 O z NI vl .A• v1 Cd 9 is Q 1L Q O r W NCL z z .0 u W :. Z z . U W Z u O Z .� Q O CIO m L rn C E L C D J 96 t CD O C v J W L O U ' m C L O �,LIOD C7Cc EO U lL (L. U. Q fn iT cc ii N U Cf) W J L O. E W. 69 O z q®q. 2 C to A �1 r=1 • r,