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HomeMy WebLinkAboutMiscellaneous - 95 SOUTH BRADFORD STREET 4/30/2018 (2)1 , 1020 Date.........!. —13. .—... 1.1 ................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... 2 .... ......... ..L ..................... has permission to perform ................ . ... .......... x .......fir- .................................... wiring in/7) the building of ....% ..................1. at ..... .................... ....... ............... //) North Andover, Mass. Fee Lic. No. 2�f�4 ,.,IV ......... ...... 'ELEcrRICALR/ llspvtcm Check # 909U Date. d : 2.( — L ( . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that W. 4 .f. Q.(. ` .. Pt �^^.�?................... has permission to perform ......... plumbing in the buildings of ....V. .................... at.'1 <; ...'�; :... , ,. , North Andover, Mass. Fee .7. .?.. . Lic. No...) 3 Q �{ ...... Ag -.-c PLUMBING INSPECTOR Check # I 1-1,F Z-- 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: N r& MA. Date:Orl ( Permit# Building Location:_ 1j _ �0 Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential FV New: ZAlteration:Ej Renovation: (] Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES Installing C;,1„pan}, Name: Y IA)6 .� Chert One Cnly Certificate J Address: p� � Jj orporation _Z171 City/Town:�r�P ,"� State:�/Q- Business Tel: _ / 7� �0 �- - /Q -7� Fax ❑ Partnership 97e Ol(o0 ❑ Firm/Company Name of Licensed Plumber: m1I//j 2 E) INSURANCE r`n��coe�.�. I have a current lia_ 6ility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate ype of coverage by checking the appropriate box below. A liability insurance policy, Other type o ' yp f 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. Check One Only 5i nature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and acc Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. urate to the best of my By V Type of nse: Title P er Dity/ Town E319laster APPROVED (OFFICE USE oNLY1 ❑Journeyman Signature of icensed Plumber License Number: 110-11-2 r. V DEDICATED H Z; SYSTEMS > Y U h z W a Uj z Z �"' Y H Q Ln U Q t-. W C� �w 1 n v1 O Q � 0 Co Ln CC LUZ _z Ln 1--;_z Q cc z Q _j 2 p c: LU z w Z v ° LL Q Q N O > O LL. O a ? N 1— W 06O N a m m o o LL= 1- S O X 3 }W— Q� o I } -SUB BSMT. 3 Q ( 3 BASEMENT isT FLOOR I ' j 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7' FLOOR 8TH FLOOR Installing C;,1„pan}, Name: Y IA)6 .� Chert One Cnly Certificate J Address: p� � Jj orporation _Z171 City/Town:�r�P ,"� State:�/Q- Business Tel: _ / 7� �0 �- - /Q -7� Fax ❑ Partnership 97e Ol(o0 ❑ Firm/Company Name of Licensed Plumber: m1I//j 2 E) INSURANCE r`n��coe�.�. I have a current lia_ 6ility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate ype of coverage by checking the appropriate box below. A liability insurance policy, Other type o ' yp f 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. Check One Only 5i nature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and acc Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. urate to the best of my By V Type of nse: Title P er Dity/ Town E319laster APPROVED (OFFICE USE oNLY1 ❑Journeyman Signature of icensed Plumber License Number: 110-11-2 r. V 7746 Date.. ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ..o .Sy This certifies that . UU.....°.L,L.......:................... has permission for gas installation . 5 .. L.C) G .............. in the buildings of ............................. at . c"l S SUu i� �� ... , North Andoverr, Mass. Fee 4 S' � v . Lic. No.l3,c '�... ..4w ,. GAS INSPECTOR Check # �f GIv" ImrLl MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING W Q City/Town: it UQ��d'�� �N%(� MA. Date: Permit# / Building Location: �'L 5 5jORL9DZAA9('-1 4Owners Name: ro Z©t1 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ GIv" ImrLl INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes O No ❑ If you have checked Yes, please indica a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnit ❑ Bond Y ❑ OWNER'S INSURANCE WAIVER: 1 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 Signature of Owner or Owner's Agent Owner El Agent ❑ By checking this box ❑; 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 COI 11 PIlanca WILII CIII rWIl1I76OL pruv151o11 UT the massacnusetts state mumomg coae ano chapter 142 of the General Laws. Typ Icense: ByI:TPlumber kv.Z-G zd��; Title ❑ Gather Signaturb of Licensed Plumber/G er [9Master City/Town ❑Journeyman License Number: lZo L%-2 APPROVED OFFICE USE ONLY ❑ LP Installer I W Z W Q Y 2 W FO W 0 0 W C0 p FCO CO) w z I- O z �- O F- Z S N w R 0 Q F row COLL] U) U Z W w Zo fn = a.0 0 � w F- W= o X LL > V W Z J I— H O m> Z J ( LL N = z Z W W LULU Q c0) o o t=i. w � w 00 00 w z w Iz- SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 3 FLOOR 4 1H FLOOR 51HFLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: ALL .P LUMI� l Al6<1 �� [ t/�G Check One Only Certificate # is �i .2corporation G Address: �a0 DC Sq,IeA, /� _ t� City/Town: trAd'jr State: N ❑ Partnership Business Tel: 1-79- 20'f 10 2c Fax: 229- 68210/&0 ❑Firm/Company Name of Licensed Plumber/Gas Fitter: a&e �it'i�1✓t— INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes O No ❑ If you have checked Yes, please indica a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnit ❑ Bond Y ❑ OWNER'S INSURANCE WAIVER: 1 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 Signature of Owner or Owner's Agent Owner El Agent ❑ By checking this box ❑; 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 COI 11 PIlanca WILII CIII rWIl1I76OL pruv151o11 UT the massacnusetts state mumomg coae ano chapter 142 of the General Laws. Typ Icense: ByI:TPlumber kv.Z-G zd��; Title ❑ Gather Signaturb of Licensed Plumber/G er [9Master City/Town ❑Journeyman License Number: lZo L%-2 APPROVED OFFICE USE ONLY ❑ LP Installer I COMMONWEALTH 0F MASSACHUSETTS IN -PLUMBERS AND GASFITTERS Z LICEpQ�fE 6 TkS&M A cjkR�OP L U M B E IP MICHAEL H WIROLL JR AN 820.SALEM RD DRACUT MA 01826-16 n5_/n1/I? R5u2xm@a_@ I Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co (MEY), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: V1 // City or Town of: NORTH ANDOVER To the In pector of Wires: By this application the undersigned gives notice of his or her i tent' n to perform the electrical work described below. Location (Street &Number) 9� .d Owner or Tenant Z11fA /C, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps /QVolts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowing table may be waived bV the Inspector o Wires. No. of Recessed Luminaires g No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat PumpNumber Totals.. Tons ...... KW .... No. of Self -Contained Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KWNo. Heaters of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value o Ele rical Work: `c -rd o f (When required by municipal policy.) Work to Start: / j Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: Unless waived by the owner, no permit for the performance of electrical workmay issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equilalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE N BOND ❑ OTHER ❑ (Specify:) I certify, under thXVI-rt4 ams and pe alties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.:�9 0 Licensee: Y/' Signature LIC. NO.: 16 (fury (If applicable, en r " empt' n the li mine) Bus. Tel. No. 169.2/ Address: G /1c/'— �S O#a 92&f:2:?Alt. Tel. No.. *Per M.G.L c. 147, s. 57-61, security work r uir Departm t of Public Safety" " License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE: $ Signature Telephone No. 6, u The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: �3 �GY�d �Y R, City/State/Zip: WC Are you an employer? Check the appropriate box: 1. Ll 1 am a employer with d-_ 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] i Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: �%�i% Expiration Date: Job Site Address:%- -3o'. &l'Cdl7l{-Gf �r City/State/Zip: (� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above i true and correct. Signature: -C J /J 4 Date• 7//� Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: C� SL Location I No. bEk-1 S-3 1)rcijklel Date ii—hoz TOWN OF NORTH ANDOVER a i Certificate of Occupancy $ Building/Frame Permit Fee $ 0 Foundation Permit Fee $ Other Permit Fee TOTAL Check # 15993 $ 3© /jj* (6 - Building Inspector PW 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: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 1'S" S ©C--, D -1t /0 3 �6 /pj Number% �7r7Pa Number /SoO� GG. V nry�a7AZ S7" 1.3 Zoning Information: /1.4 g2 sAcd�'" /U�^'d3c1�•/ o Sf-�I Property ensions: U-- S -s 0 cf Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 33 s/ J,,,00/ 1.7 Water S ly M.GL.C.4t1. 54) 1.5. !Zone Information: 2 1.8 Sewerage Disposal System: ::] Public Private ❑ Zone Outside Flood Zone ❑ Municipal 'Jr On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record GC � C �/ z3— P, -0 Name (Print) Address for Service: (eFa) 5/ -S -6"-7-S20 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable} Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Con ctor Not Applicable ❑ 3121 Company Name 07 ����a�— Registration Number 3�1����/ Address Exp iration Dat Signature Telephone Opt rn SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted th this application. Failure to provide this affidavit will result in the denial of the issuance of the building Signed affidavit Attached Yes ...... o.......0 e's Geri ie O SECTION 5 Descri tion of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other 1Q7- Specify S Brief Description of Proposed Work !2' , SF,CTTON 6 - FSTTMATFiI CnNCTR1TrTinN rnCTQ 1 Item Estimated Cost (Dollar) to be Completed b ennit applicant OFFICIAL`USE ONLY 1. Building,::.. � z Z �© (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection ---- 6 Total 1+2+3+4+5 © Check Number a>MIWiN is UW NEH AU IHURIZATION TO BE COMPLETED WHEN OWNERS AGENT OR�COONTRACT`O'R/APPLIES FOR BBUH.DING PERMIT 1, 7;( r 1 r1� c'� l / �`I_ -1, 4Z -0l as Owner/Authorized Agent of subject property It Hereby authorize Sk to act on My behalf, in all matte r to ork authorized by this Alding pennit application. Signature of O vTi v/I SECTION 7b % Vv YE AUTHORI/ZED AGENT 6ECLARATION 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 & A�' Print ame %6/Z T/ / p Sianat ue of O er t / r v� i a fltflate ! NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TBMERS 1 ST 2 ND 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHDRTEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE /0 -23 -*1 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. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT r3C- �Vz-C2 PHONE�6S'K 77j 2 C� LOCATION: Assessor's Map Number 6 3 PARCEL /0/ SUBDIVISION /,�/x MO. S -S 2 2- LOT (S) 2� STREET "/'O1 �7- ST. NUMBER 07S ************************************OFFICIAL USE ONLY*********************************** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRA 13 DATE APPROVED f -3/-6� ✓� DATE REJECTED COMMENTS �� TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm ,m 9. m m z� 3 +� o .x N m N N m n 0 C I� rr- D Z Boz 30 �m Ut m NM' M 61 r 0 m Oct 07 02 08:54a . I , Eastern Shed 19786884244 Q p.2 \a�.dprt rclr� Z 0. 24520 �oUS o.1w 0 4 16 r OGm~� r� m N� O c . V-� 'otr� FII=IGATE OF LIABILITY INSU��ANC P DJCE PAGE f ., (976) 3 74 -63 52 DATE (MM7DDIyy) �ENS INSURANCE AGENCY FAX (378)521-51ZJ 10/04%2002 imball St. ONLY AND CONFERS NO RIGHTS UPON l'HE GERTIFICATL 46 AER NEHIS GpVERRAGE A FOATE p DOES BY THE POLICIES; E EBELpW MA 01835 rn _>hed Corn an INSURERS'4FFGRDING CpVER AGE rthr;lmes ,IncINSURER A; Worcester IkIUrdM[e CO. tead, NH 03841 INSURER � AIG Insurancernee CINSURER CINSURER D;ERAGES NSURER C A A �nnrv�:t LISTED HELOYy ygVG SEEN ISSUED TO THE INSURED NAMED ABOVE FOR TFIE POLICY PERIOD INDICg7Ep, ANY REQUIREIUIENT, TERMOR CONDITION OF ANY CANT MAY PERTAIN, THE INSURANCE AFRO RpED BY THE P ( R.ACT OR OTHER DOC I I' POLICIES. AGGREvP,7E LIMITS SHO'N;; OL GcS DEaCRiBED NEG' gIJECESPALL THE WHICH THIS N1I HAVE BEEN REDUCED 6Y p O G S CERTIFICATE MAY'l R TYPE Of INSURANCE " I0 CLAIM 1 ERfv15, E3(CUUSIQN$ AND CQh GENERAL LIABILI POLICY NUMBER .L. PA6E1162 DATE (&1MIDDlrY) DATE (Mlw•UDmy C X COMLAAIglGiENER.gyIA61LITY 11/15fz001 11115/2002 EACHOCCURRENCE LA,MSM/IDE I x OCCUR i �_J FIRE DAM.A GEN'L AGGRE:;ATE UMIT Ap� pa Z. POLICY F-1 EIECT I I LCC AUTOMOBILE LIABU'[T V ANY AUTO ALL OWNEDAUTO$ X SCNI:pvu;DAUTOS X HIREDAUTOS C NON-OWNEDAUTOS GARAbt: LIABILITY 7 ANY AUTO EY.CESS LIASILITY X OCCUR �-! CLAIMS MADE A _1 I CTteLE X RETENTION 3 WORKERS COMPENSATION EMPLOYERS' LIABILITY B GE (Any one 8r, MED E}fP (Airy 9110 person) PERSONAL 8 AAV iN.RiRy GENERAL AG GREGATE RROOUCTS•COMPlOPAG ISSUED OR TIONS OF SUCH (tom aeoltlInt51NCLE LIId IT S ) I BODILY INJURY (PerPersm) S I, BODILY INJURY (Pcr accident) $ PRO c TY PAIII S ftr 1 AUTO ONLY• I=AA"IDIS 'IS OTHER THAN EA ACC ( g 62 AUTO ONLv; kGG 11/15/2001 iS 11/1S/zaaz EACHOCCURRENCE �g AWREGATB Q ADDITIONAL INSURED; INSURER LETTER. Eric Kozol 95 South Bradford Street N. Andover, MA Oz845 FAX: (617)557-9908 P --L- EACH ACCIDENT EL. DISEASE --�— E.L. DISEA— LIey ;0 �5 11100 Ldad 21000, S00. 1,000 SHOULD ANY OF TME ABOVE DESCRI6E0 POLICIES BE CANCELLED 6EFORE EIPIRATION DAI THEREOF, TNN ISSUING COMPANYWILL ENDF.AVQR TO MAIL –ID— DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO -HE LII BUT FAILURE TO MAIL $UCH NOTICE SHALL IMPOSE NO OBLIGATIONI OR LIABILITY OF ANY MD UPON THE COMPANY, ITS AGENTS OR REPMENTATN'ES. THORIZED REPR>= I lliam Costello C/) m m Cl) U m CO) .p Cl)CD Z CD O ar d O Y O o p CD CT CCD O F -W -.7m .. y CD 0 i -J d Cl) CD O rF CD CD H. CD H co 0 C co C C p d _ O -• co) Q' N d o m y Cl) m m CAc')no m Z y' y' o, �:m y r, CL CL 0m �CD �o H C y M f =m . o _ > > m c C Oo o� n 0 0 y' a o 7 R i lid N CL Y n VJ m m N Cn D n� CCD = � Q1 D1 O p 15C. N : _ C A _cn Fr CD. :� CD tf CD ;O O (o Cl: Q o cl) o o : C� co 0 �. r = =r : :ID l�j o ca CD C U' d 0 O =r: r: C n� W 0 CU n:cl = o O 0" y 0 0 c �,' o o ►n.3 M cp o n b O �? o 'ted O m n 7o o C 0 � � w n rDC o \ Qy C�7 y 0 0 c TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING a BUILDING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioner/Inspector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number:- -zqaig, to? t Map Number Parcel NumberZ Z p��{-2A 1.3 Zoning Information: 1.4 Property Dimensions: Ilk - da�- 5. , I? y. 76 Zoning District apega. Proposed Use ea s Frontage ft 1.6 BUILDING SETBACKS 11 Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water S ly M.G.L.C.4o. 54) 1.5. pF-l�ood Zone Information: Public Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record LT -S 11 Y, �� 2®L Name (Print) Address for Service: �j 7—S2 Signature Telephone 2.2 Owner of Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable Licensed Construction Supervisor: License Number Address Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ �� EA-S/�y 5H6-12 cb�y- yx-(, k) � 133 3 2.S�- Company Name t-0 *4 Regtstratton Number 43_ R SS �� Address p� — �r -W Expiration Date Signature Tele hone Ma rn X Z O SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this app 'cation. Failure to provide this affidavit will result in the denial of the issuance of the building rm' . /)-Sv>''-"Ge_ Signed affidavit Attached Yes ..... No ....... 0 SECTION 5 Descrition of Proposed Work check all applicable) New Construction ❑ Existing Building 11Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Conlpleted by permit applicant OFFICIAL USE ONLY - 1. Building�0�, <�' (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (8) 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 4co l as Owner/Authorized Agent of subject property Hereby authorize EC- n 9W Coe-11to act on My e alf_ma,fte s rel t ve to work authorized b b '1 mg permit application /D. �� , 2— Si atiue of Owner Date SECTION 7b OWNERJXUTHORIZEID AGENT DECLARATION I, ;(13C-1 doe -os- ACr' X S, � ,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 f Aozo/ Pr'n ague % /10 702- i ature of O /A Date A, 6 mmi.� NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS iST 1ST2 ND 3RD SPAN DfMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERLAJ, OF CHIMNF_Y 1S BUILDING 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. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICANT Xo -o I PHONEq7l�_Oi _ �0 LOCATION: Assessor's Map Number PARCEL lb SUBDIVISION fltA A. - LOT (S) STREET �a l ST. NUMBER ************************************OFFICIAL USE ONLY*********************************** REC MENDATIONS OF TOWN AGENTS: CONSERVATION ADMINIS ATOR DATE VED E REJECTED // ;t COMMENTS er -4,1 Edo y (V/fs1 SO' no — {awl IJ of w ef), ,gl010o k (,.S'Cct,"CZ_ TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH le]LtL C DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9\97 jm E LOT 1 3 t').00 SouT'Li g aADV'oFx%-'* "'� 4c,'Be — THiS PLAN IS BASED ON A TAPE SURVEY (NOT AN INSTRUMENT SURV" AND 19 TO BE USED FOR MOPrT.LpE oURPoSES ONLY. THEREFORE THE OFFSET$ AS SHOWN SHOULD NOT BE USED TO ESTABLISH PROPERTY LINES. "E; sS6 x COUNTY DEED REFERENCE: PIAN REFERENCE: PLAN OF LAND BK. \oby PG. ZZ'S PL EIK� 55Z2.PL IN CERT. NO. 6K. PG. 10/04/2002 14:27 978-521-5127 COSTELLO INS. PAGF F11 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DMW) —�� 10/04/ZO02 9INSURANCE AGENCY 4-6352 FAX (978) COSTELLO INSUR521-5127 IN 2 South Kimball 5t. ONLY AND CONFERS NO RIGHTS UPON THE aRTIFICATE HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ANA THF COVERAGE AFFORDED BY THE POLICIES BELOW. PO BOX 5248 Bradford, MA 01835 INSURERS AFFORDING COVERAGE INSURED Eastern Shed Company, Inc INSURER A; WorceSter Insurance Co. 39 Sarthelmess Lane INSURER 5C AIG Insurance Company Hampstead, NH 03841 IN$URERC: EACH OCCURRENCE S 1 000, 000 INSURER D; MED EXP (Arty one permn) 3 S 000 INSURER E; R.0 V EnLwk2r a YHE POLICIES OF INSURANCE LISTED 5ELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAT90'NOTWITHSTANDING ANY REQUIREMENT, TERk1 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDEC BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EKOLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGPTE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM$. LTR TYPE OFINSURANCL POLICYNUMBER DATE{MM/O& M) DATE(NNMDD/YY) LIMITS Aff�� GENERAL UABILITY X I COMMERCIAL GENERAL LIABILITY CLAIMS MADE r X + OCCUR WPA6E1162 11/15/2001 IV15/2002 EACH OCCURRENCE S 1 000, 000 FIRE DAMAGE (Any one Fre) 3 50,000 MED EXP (Arty one permn) 3 S 000 PERSONAL& ADV INJURY 3 1,000,000 GENERAL AGGREGATE S 21000.000 G6N'L AGGRGGATG LIMIT APPLIGS PER: POLICYF150 LOC PRODUCTS - COMP/OP AGG S Z , 000, 000 AU'MMOBIICLIAgILM X X X ANY AUTO ALL OWNEDAUTOS SCWEDU4EDAUTOF, HIREDAUTOS NON-OWNEDAUTOS RA6EU62 11/15/2001 11/1512002 COMBINIIZIWLELIMIT S (8a aecatlenq 500,00 BODILY INJURY (Perpersm) s BnO�DILYINJURY (Pcr kgiddrW) $ PROPERTY DAMAW S {>"er accWsN3 GARAGE LIABILITY ANY AUTO AUTO ONLY • EA ACCIDENT 3 OTHER THAN EA. ACO 3 AUTO ONLY: AGG 3 A EXCESS LIABILITY X OCCUR C] CLAIMS MADE DEDUCTIBLE X RETENTION S BESE1162 11/15/2001 11/15/2002 EACH OCCURRENCE 3 1900.000 AC4REGATE $ 1, 000, 000 3 S S B WORKEMCOMPENSATIONAND EMPLOYERS' LIABILITY WC2160612 04/11/2002 04/11/2003 TORY LIMIY5 ER__ El_ EACH ACCIDENT S 10010 00 E.L. DISEASE - EA EMPLOYM 3 100,000 E.L. DISEASE - POLICY LIMIT I S S OO 000 OTHER DESORIFTION OF OPEMTSpNSILOCATIONSIVENICLES/EKCLU310NS ADDED 6Y CNIiOi45jrNT/6PECL4L PROVISIONS vr,i• I I N4ulsiynr,u 1JV1iGR Y�iI �GRv—^'•—�—�-'••�' Eric Kozol 95 South (Bradford Street N. Andover, MA 01845 SPAY- r9171CC7-G®nR SHOULD ANY OF THE ABOVE DESCNIBEO POLICIES BE CANCELLED BEFORE Int EXPIRATION DATE THEREOF, TH9 ISSUING COMPANY WILL ENDEAVOR TO MAIL 10. __ DAYS WRITTEN NOTICE TO THE CERTIFICATE; mows i NAMED TO THE LEFT, BUT FAILURE TO MAIL SQOH NOTICE SHALL IMPOSE NO OBLIGATION ORLIAVILMTY OF ANY IOND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. Willi 303 Date .. A ,&ORT1y TOWN OF NORTH ANDOVER pb. ao ,e,�ppL p PERMIT FOR GAS INSTALLATION This certifies that../ • ... • • ....o has permission for gas installation ...��/f ../.. .� : �... in the buildings of .. �t r? ! a fl: �........................... . at , / .. 0...��.�`*c!-,"=f.: l • • • • • • • • • , North Andover, Mass. Fee `?�.v ... Lic. No�f�: x`11... .......................... C `lv77 !CANARY: GAS INSPECTOR WHITE: Applicant Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DOASFITTING (Priurntt or Type) Mass. Date /� =19 ' Permit #�r-�/ Building Location,+L �.�% Owner's Name a . Type of Occupancy New a-- Renovation ❑ Replacement ❑ , Plans Submitted: Yes❑ No ❑ Installing Company Name .01 Business Telephone Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership Certificate 7 INSURANCE COVERAGE: 1 have a current (hilly insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes M- No ❑ ' If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Gir" 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 walves this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ i hereby tartly 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 permit i ued for this application be In corrtplia with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the G eral taws. 8Y T e of Ucense: 144 /1'/,�'O" Plumber i natur ocense um er or titer Title lifer aster License Number City/To"Journeyman FM yl - 71 N H rr W N N N V r to U2 W Q J N N W cc O O U O m N t �„ X 7f �_ U:1,_.0 >-Z ,z < m N W iu- .4 'awl W O 1. {/J a C d 1- 01 W rt ... W 2 v W x s W < 0 W In W F. W S J „� F- f. W W 0 o k F- v W < W > tr W << O O W C' S O t7 X Y. 7 O d J V > O d F` O SUB—aSMT. BASEMENT ISTFLOOR 2ND FLOOR � I I 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name .01 Business Telephone Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership Certificate 7 INSURANCE COVERAGE: 1 have a current (hilly insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes M- No ❑ ' If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Gir" 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 walves this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent ❑ i hereby tartly 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 permit i ued for this application be In corrtplia with all pertinent provisions of the Massachusetts Stale Gas Code and Chapter 142 of the G eral taws. 8Y T e of Ucense: 144 /1'/,�'O" Plumber i natur ocense um er or titer Title lifer aster License Number City/To"Journeyman FM yl - 71 30'1 J Date .�a' ��; .... . f PORT e,�O TOWN OF NORTH ANDOVER o or PERMIT FOR GAS INSTALLATIO% s U • y7 o CL ,SSACHUSEt This certifies that .- � .. `. ......... � • • • • • • ...... • • • • • •Pd has permission for gas installation .. �. in the buildings of ./......... ........ • • • • A, at ....... North Andover, Mass. Fee.,).?-.-.-.. Lic. No..3 <<.:! .... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING wrirrntt ar T,y✓pje) �c/ Tf!JirC /Jip , Mass.. Date Permit # e3 Building Location ����fJ�owner's Name Type of Occupancy New M-""' Renovation ❑ Replacement ❑ . Plans Submitted: Yes❑ No ❑ Installing Company Business T Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership Certificate it INSURANCE COVERAGE: I have a current I_ tabli#ty insurance policy or As substantial equivalent which meets the requirements of MGL Ch. 142 Yes � No ❑ ' If you have checked ye. please indicate the type coverage by checking the appropriate box I A liability insurance policy (R 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: Signature of Owner of Owner's Agent Owner❑ Agent ❑ i hereby ceruy that all of the details and information 1 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 permlt i ued for this application be In comptla with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G eral Laws. eY T e of Ucense: Plumber i natur o Ucensed Pluffi6e_r­or­C��—itter Title eller aster Ucense Number _,&,,, CitAPY Journeyman N ' N W N N N V V1 N a: N N R O W S }. J a: r�< z .o r- W < S m N 4! F- < W O t-� O N d C ri > F W Z V W N W< CZ f- J }• r. W W O O i < W > ¢ W '• fC < < O O W > O F- o C'= O Y. O O O J U C G 6 F` SUB—BSMT. BASEMENT 1STFLOOR 2f{0 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR f 7TH FLOOR a-rH FLOOR Installing Company Business T Name of Licensed Plumber or Gas Fitter Check one: ❑ Corporation ❑ Partnership Certificate it INSURANCE COVERAGE: I have a current I_ tabli#ty insurance policy or As substantial equivalent which meets the requirements of MGL Ch. 142 Yes � No ❑ ' If you have checked ye. please indicate the type coverage by checking the appropriate box I A liability insurance policy (R 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: Signature of Owner of Owner's Agent Owner❑ Agent ❑ i hereby ceruy that all of the details and information 1 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 permlt i ued for this application be In comptla with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the G eral Laws. eY T e of Ucense: Plumber i natur o Ucensed Pluffi6e_r­or­C��—itter Title eller aster Ucense Number _,&,,, CitAPY Journeyman Location NO. -7 Date . v NpRTN TOWN OF NORTH ANDOVER f � • � t 3? ' _ Certificate Occupancy $ of �'�s'•E<� a^CHus Building/Frame Permit Fee r $ -44 Foundation Permit Fee $ Other Permit Fee $ TOTAL $� Check #31'r' 0 Gl/ Building Inspect , c TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 01 BUILDING PERMIT NUMBER: cR a/ DATE ISSUED: ® 0® a, e C s SIGNATURE: Building Co missioneEjaywtor of Buildings Date SECTION 1- SITE INFORMATION 1.1 Prop ddress: 1.2 Assessors Map and Parcel Number: M NiiParcel Num 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide Reqwred Provided R red Provided 1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2. wner of Record r !J ame(Print) Address for Service Signature Telephone 2.2 Owner of Record: 1 ame Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ Vefi ed Constructio u rvisor: D/CJ License Number As .�1%l�• D34 99DDS Expi tin bafe Signa a lephone 3. egistered Ho provement ntractor Not Applicable ❑ om a en %J %/ Regi t tion Number A re Z/ le9vliv Exp' ion Da e Si na a IVTelephone 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 ❑ Other ❑ Specify BriefDescriptionof Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL VSE ONLY ; 1.xaa,� (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 7 WNER AUTHOR TIO TO BE COMPLETED WHEN O ER GENT R C T COR PLIES FOR BUILDING PERMIT I, as O er/Authorized Agen subject property reby authorize to. act on y behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, 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 Signature of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINMERS iST2ND 3 RD SPAN DUVENSIONS 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 J, FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT PHONE SSESSORS MAP NUMBER 4LOT NUMBER_ DIVISION OT NUMBER STREET TREET NUMBER OFFICIAL USE ONLY v.� 0v RECOMMENDATIONS OF TOWN AGENTS k LQ DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED t COMMENTS c � 2 � S DATE APPROVED O TO R DATE REJECTED T) COMMENTS DATE APPROVED ` FOOD INSPECTOR-. TH DATE REJECTED (� DATE APPROVED c5 D SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS — SEWER / WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED CONIlyIENTS RECEIVED BY BUELDING INSPECTOR Town of North Andover o* Na RTF, �ti0 a� 6, 5.. ° O Building Department o 27 Charles Street * _ North Andover Massachusetts 01845LA 1 a► (978) 688-9545 Fax (978) 688-9542 44;q`""" 5 Ss Lis DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit 9 the debris resulting from the 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 I, Facilifv location Sieature of Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. -S� QIQ 1 O P4 a O co x U W W O W Qc • � : ev cv z c Z w Q z tts U •mom M b V v Oor- uv Q Ec U p C/)0 TJ C 00 u E E y A w z v a w cn C C w2 1:04U w C ap' w C 0cn w p C a u. m cn 1 c c co woy • Qc • � : ev cv c .� ev In t E Q tts •mom M b o n fg 40 Ec wo V Qf me E E y A � mm � y 3 _ =MV=Mui D.3 v m y:Ey O • m -lob : m :a== :mom m r c C O cm c CD Col. - o ►— m W cJa is O Vl d= C oc E L3.0 0y Z o m om�s g LO d m .5 O A .0 H •= 0 = = � 0.- T 2 co 0 O O 0 CD 3� CD O o CD v. a cm4 C � C .O O O Z CD CL ti C LLI C) Lli U) Ccw LU IrW