HomeMy WebLinkAboutMiscellaneous - 96 LOST POND LANE 4/30/2018r
.J�_ Commonwealth of Massachusetts h
City/Town of j ti� 2014
System Pumping Record NORTH ANDOVER ¢ TOWN OFNORTH ANDOVER
t HC=ALTH DEPARTmENT
.y
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351,
A. Facility information
Important:
When filing out � Y
1 System Location:
forms on the C/— , f
computer, use -. __.--_ [t L05--- _t1'lt 1only the the tab key Address
to move your !.tl-'!.14�tL/0L�_
cursor - do not Ciyl7own State Zip Code
use the return
key. 2 System Own
S� N
ame
+�^ Address (if different from location)
— State Zip Code
lTo
Citywn
Teie hone umber
B. Pumping Record
1. Date of Pumping -- --- 2• Quantity Pumped:�w-
Date Gattons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YegNo If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of System:
6 S t Pum ed B
yo
Name
Vehicle License mber
Cortpany
G.L.S.D.
7. Location where contents were disposed:
North Andoven SIA.
Signature of Hau er
Date
-- - - .. -- -- --
Signature of Receiving Facility
— — - -._..— ..-------- - — — --- -- --- ..
Date
15form4.doc• 03/06 System Pumping Record • Page t of 1
North Andover MIMAP March 18, 2014
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Hon-tal Datum: MA Stateplane Coordinate System, Datum NAD83,
Meters Data Sources: The data for this map was produced by Merrimack
flikol y Valley Planning Commission (MVPC) using data provided by the Town of
O� i�ao , Ati North Andover. Additional data provided by the Executive Office of
Environmental Affairs/MassGIS. The information depicted on this map is
L for planning purposes only. It may not be adequate for legal boundary
to
definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
" ry THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
^ OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
off. `a • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
North Andover MIMAP March 18, 2014
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Dea
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definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
Zoning Overlay
fl 1 District t
MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
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312 District
THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
00 Downtown Overlay District
13 Industri
3 District
4
OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
Historic
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Residece
:: S District
I Dis i I•
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THIS INFORMATION
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Date ...... 4/:7 /7:-!/7.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that / / CA/?lt � G7' .........................
.................................................
has permission to perform .................................
r
wiring in the building of ..........J:74..C�—..................................................
GO i �oh� ........... . North Andover, Mass.
!�¢
Fee ..................... Lic. NoPP�F..� ....... f i F?� ............
ELECTRICAL INSP�,ICI'OR J
Check # 565 �' f
73 12
Commonwealth of Massachusetts Official Use Only
Permit No. 2—
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC). 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /-% I i % jl0 1-7
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)
Owner or Tenant G -(-V Y- SCA,C: o a Telephone No.
Owner's Address SG`MQ_
Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box)
Purpose of Building Gin Utility Authorization No.
Existing Service Amps / Volts 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: t SV-, C)vr1
(Dk 4) 1 +E-; 4 �'\
Completion of the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires j
No. of Ceil.-Susp. (Paddle) Fans
No. OT— Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- El.
rnd. rnd.
o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
of Detection and
No. Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ Munic'pal ❑ Other
Connection
No. of Dryers
HeatingAppliances
pp KW
Security Systems:
No. of Devices or Equivalent
No. of Water KW
Heaters
No. 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 of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: V" � Ccc V L LIC. NO.:�1¢
Licensee: P,� C V. P` cc 1d •' Signature s LIC. NO.:
(If applicable, enter "e 1n t" int license number lin . Bus. Tel. No.: a3/- /37
Address: _I_� ( �CY Alt. Tel. No.: kL(LI-7! 0
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" 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 agent.
Owner/Agent FPERMIT FEE: $ —�
Signature Telephone No.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' a 600 Washington Street
Boston, MA 02111
Y www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. ❑ I 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.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
*Any applicant that checks box #I 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 anew affidavit indicating such.
'Contractors 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. #:
Job Site
Expiration Date:
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 is true and correct.
Signature: Date:
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 #:
-,•,-, v ` _ .t, � ...� Y-_. .... .v`". .. - . ti=...2.. .. .sem ...11rri. /._ ..- _ •
Date .....&?- ..�% •
428
t N°RTM
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to perform ............... ................ .. . ....... ...............
wiring in the b ' ding of �j C!...... ..
at . '11 .......1/ .........lil?(,.. ..../ .�............ .North Andover, Mass.
FeeOU Lic. NoIVSS �
..............................................................
ELECTRICAL INSPECTOR
�-*&
foo zie. WIA n �
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
C� Ottica Use Onry
_'� Liil� L':jjjnjiutjllllEL'I�lll �`ar1i��t5 Permit No.
r r
O
Occupancy & Fee Checked
_ Be;IFlitjnzj t Qf-VUf31IL �"SfE2T� .
GV am No
blank)
^ BOARD OF FIRE PREVENTION REGULATIONS X27 C'<iR 12:00 t3 23
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cade, 527 C: R 12:00r
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date
(j)� or Town of NORTH ANDOVER _ To the In of wires:
The udersigned applies for a permit to perform the elec* ical work described below.
Location (Street & Numbe _�/i( --! CA--
Owner or Tenant /V,/,- Z-0 i
/moon
Owner's Address _ _
is this permit in can :ian ,wiith a buildii permit: Yes t� No _ (Check Appropriates f1705—&
Scx)
Purocse of Building C fL Utility Authorization No.
Amps _J Veit_ Overhead _ Ur,cgrnd No. of Meters
Existing Sarvicev
_
_
New Serlice Amos Voits Overread _ UncSrna iy No. of Lteters
Numcer of Feeders ana Amcacity
Lccaticn ana Nature of Prccosed Elect^cal .'/crx
No. of Lignang Outlets
No. of Lighting Fixtures
No. of Recectacte Outlets
O i No. of n,,. 'gs
Sw:mm:nc Poo:
No. of Cil Eur hers
Above– In- - :
grna. — crnc. _
CTHE?..
Tota:
No. of Transformers KVA
Generators
No. at Emergency Lighting
3arery Units
FIRE ALARMS No. at Zones y
No. at --election ana
initiating Oevtces
Na. of Souneing Devices
No. of -;an Contained
Oetec::aniSouneing Devices
1
Lcca:
— Muntcioai Othar
— Connectton _
KVA
Law Voltage
vvinnc
INSURANCE CCVERAGE: Pursuant :o the recuvemencs of • Iassacnusa-s general 'Laws _
I have a current Liao:iity Insurance Policy inciuc:ng Cc:^o_ .e Oeerauens Coverage or :;s sucs;anual ecuiva:enc. YES VO _
have suomrrteo valid proof of same to the Office. YES _ NO _ If •;cu nave checxea YES. pease inaicate the type of coverage cy
cnecxtng the aopr0 to cox.
INSURANCE 3CNO = OTHER = lP!ease Stec:!•/) (Excirauon Oatei
Estimated Value of E'.ectrical •Nork 5
Werx :o Start inscec::on Oate Racuestac:
Signed unser :he P>n�te f per11 Z,– C
RiaiLt .NAM
Rougn /•(//1_4.: 1-L r=inai
LIC. NO.
C Signature
Licenses � ,% // ' //� // ,✓/ �1 d -3 a
/ Jv� / Vot /��1 ` /�/ tel. Sus. ;el. No.
Alt. Tel. ^fa.
Address !n/o.
OWNER'S INSURANCc WAIVED: 1 am aware that the L:censee goes not nave me insurance coverage or is suostanoal eaurvalenA ent
au:rea oy
Massacnusetts General Laws. ana :not my sgr.a;tire on :n:s term:c aopucat:on '.varves this reawrement. owner g
(P!ease cnecx one)
eiecnene No. ADMIT r__
(Signature of Cwner or Agenti
No. or Gas=urners
I
No. of Sw tcn Cuttets
Total
No. o f Ranges
_
_
i No. or Air cnc. tons
Heat otai
Tocai
No. at Oiscosals
NO tf Pur-gs Tons
K"V
� SeaceiArea i -!earn°
No. or Oisnwasners -
/
I Heattna Devices
�V
No. of Criers
No. gt No. or
No. of .Vater Heaters
KVV
i Sicns Sa:ias;s
Nn 'Hvnrn Massace Tubs
I No. of Mcccrs Total Ho
CTHE?..
Tota:
No. of Transformers KVA
Generators
No. at Emergency Lighting
3arery Units
FIRE ALARMS No. at Zones y
No. at --election ana
initiating Oevtces
Na. of Souneing Devices
No. of -;an Contained
Oetec::aniSouneing Devices
1
Lcca:
— Muntcioai Othar
— Connectton _
KVA
Law Voltage
vvinnc
INSURANCE CCVERAGE: Pursuant :o the recuvemencs of • Iassacnusa-s general 'Laws _
I have a current Liao:iity Insurance Policy inciuc:ng Cc:^o_ .e Oeerauens Coverage or :;s sucs;anual ecuiva:enc. YES VO _
have suomrrteo valid proof of same to the Office. YES _ NO _ If •;cu nave checxea YES. pease inaicate the type of coverage cy
cnecxtng the aopr0 to cox.
INSURANCE 3CNO = OTHER = lP!ease Stec:!•/) (Excirauon Oatei
Estimated Value of E'.ectrical •Nork 5
Werx :o Start inscec::on Oate Racuestac:
Signed unser :he P>n�te f per11 Z,– C
RiaiLt .NAM
Rougn /•(//1_4.: 1-L r=inai
LIC. NO.
C Signature
Licenses � ,% // ' //� // ,✓/ �1 d -3 a
/ Jv� / Vot /��1 ` /�/ tel. Sus. ;el. No.
Alt. Tel. ^fa.
Address !n/o.
OWNER'S INSURANCc WAIVED: 1 am aware that the L:censee goes not nave me insurance coverage or is suostanoal eaurvalenA ent
au:rea oy
Massacnusetts General Laws. ana :not my sgr.a;tire on :n:s term:c aopucat:on '.varves this reawrement. owner g
(P!ease cnecx one)
eiecnene No. ADMIT r__
(Signature of Cwner or Agenti
Location ,?Z,
�
• No. 21 11
Date
NORTH
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
swcNus
CHU
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $ Z9
Building Inspecior
�o 131/98r 49.50
31.54 PAID
Div. Public Works
Location
• No. _
i
f
sswc MusE�
Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building Inspector
07/31/98 09:50 31.50 mT"
Div. Public Works
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
***"**"APPLICANT FILLS OUT THIS SECTION*
APPLICANT %� 06rn-19-s
LOCATION: Assessor's Map Number.
SUBDIVISION j (� t
STREET `G LT os Pond ! n _
RHONE W - M-30?
********* 'O F F I C IAL USE ONLY***
PARCEL
LOT (S)
ST. NUMBER �I
RECOMMENDATIONS OF TOWN AGENTS:
IWQ�
CONSERVATION ADMINISTRATOR DATE APPROVED
,DATE REJECTED
COMMENTS �/ V W ��%-�`��J� K-)
TOWN PLANNER DATE APPROVED
APDATE REJECTED
lie COMMENTS
47 d- C�-3"f�/f P E �gio�VV�1rS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
PECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS 9-4-k Gzy lcr--- s t,�� ��G "f'G �T �,•'a,
c
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
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Location
No. - Date -7
,A/a /�'7�
TOWN OF NORTH ANDOVER ,'
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
g
Other Permit Fee
$
Sewer Connection Fee
l`
$ M
Water Connection Fee $ /077.1,D
TOTAL
_.,Ad' Inspa or
t�r
9 a 9 Div. P? iWorks
Location
No. Date
9G
TOWN & NORTH ANDOVER
Certificate of Occupancy $ k
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $ g
Water Connection Fee $
TOTAL $ --�—
Building Inspector
Div. Public Works
Location
C No. Date
t
y�Z7
TOWN OF NORTH ANDOVER
Certificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL
+ -Y?
q u/96 10:56
Building Inspector
847.00 PAID
Div. Public Works
PERAHT NO.
—7=
APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS.
PAGE 1
MAP'h40.
LOT NO.geT �Z J S'� 3 t ? S
2 RECORD OF OWNERSHIP iDATE
BOOK 'PAGE
ZONE
•
SUB DIV. LOT NO.%rNTL
oC /AJ( 6 5-1
Z7Z 3D
LOCATI
Lb5 F PaNb L.ANe
PURPOSE OF BUILDING
OWNER' NAME ` / be �N�
t-
NO. OF STORIES SIZE /1/J�1JV i0/
-F//,y
OWNER'S ADDRESS /9 D _5 3 f N. #,VoLj�rC
J
BASEMENT OR SLAB RSe n b N /
ARCHITECT'S NAME �j�f �r ,y�7C
J
SIZE OF FLOOR TIMBERS IST �/ �a 2ND �X JD 3RD
BUILDER'S NAME �Of//�� ���
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILL �X
POSTS LL 9J)y(/-0 JOM /V s
DISTANCE FROM STREET 00
DISTANCE FROM LOT LINES - SIDES�� REAR /SO
GIRDERSL/_ 1 )O
AREA OF LOT FRONTAGE /DO
/
HEIGHT OF FOUNDATION 2' jo ff THICKNESS /O
r
IS BUILDING NEW 1/p <
SIZE OF FOOTING a X O
IS BUILDING ADDITION No
MATERIAL OF CHIMNEY er�-Q,r
IS BUILDING ALTERATION No
IS BUILDING ON SOLID OR FILLED LAND
WILL BUILDING CONFORM TO REQUIREMENTS OF CODE I/e5
i
IS BUILDING CONNECTED TO TOWN WATER �'e C
BOARD OF APPEALS ACTION. IF ANY /V L
IS BUILDING CONNECTED TO TOWN SEWER IVO
IS BUILDING CONNECTED TO NATURAL GAS LINE Na
T INSTRUCTIONS
SEE 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/ 3/(7
L
AGENT
-a -,75(o -'
PERMIT GRANTED
'#'`'
JUL 1995
3 PROPERTY INFORMATION
LAND COST o, Q a O
EST. BLDG. COST 745, iWO
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
-/$eBUILDING INOPKCTOR
OWNER TEL. X olcu_���
a CONTR. TEL. J/ `� ? 8 ( �,5T?
CONTR. LIC. k (2:2, S12
`Z
H.I.C. k
1 OCCUPANCY
SINGLE FAMILY ISTORIES
MULTI. FAMILY OFFICES
APARTMENTS
CONSTRUCTION
2 FOUNDATION
8 INTERIOR FINISH
CONCRETE
_
PINE
a
1
2 13
CONCRETE BL'K.
BRICK OR STONE
_
HARDW D
PIERS
PLASTER
_ DRY WALL
UNFIN.
_
/
3 BASEMENT
AREA FULL
'/. 1/2 1/
FIN. B'M'T AREA _
FIN. ATTIC AREA _
NO B M
HEAD ROOM
FIRE PLACES _
MODERN KITCHEN
4 WALLS I 9 FLOORS
CLAPBOARDS
DROP SIDING
B
1
2
�_
3
_
CONCRETE
WOOD SHINGLES
ASPHALT SIDING
ASBESTOS SIDING
VERT. SIDING
_
EARTH
HARD\!✓'D
COMMC:N
ASPH. TILE
STUCCO ON MASONRY
STUCCO ON FRAME
BRICK ON MASONRY
BRICK ON FRAME
CONC. OR CINDER BLK
WIRING
5 ROOF II 10 PLUMBING
GABLE I I HIP 1 11 BATH 13 FIX.) 1
OT
SLATE $HINGES NO KITCHEN SINK
�IL MBING I�
TAP A rPAVFI I TAll
��) TILE DADO
66 FRAMING 11 HEATING
HEATING
WOOD JOIST PIPELESS FURNACE
FORCED HOT AIR FU$
TIMBER BMS. 3 COLS. STEAM
STEEL BMS. & COLS. HOT W'T'R OR VAPO
I
7 NO. OF ROOMS
Ist 13rd 1 11 NO HEATING 1 I
BUILDING RECORD
12
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.
FORM U - VERIFICATION 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:
APPLICANT: Rf-J-LOCL N C Phone
LOCATION: Assessor's Map Number o Parcel re ro fi
Subdivision _ &.5/�ow0 Lot(s) _
Street L„ os �a 11.6 L ��e - St. Number
************************Official Use Only************************
RECO NDATIOgF TOWN AGENTS:
Date Approved 71, -�A�,,:7
C servatio Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected '
Comments
Food ector-Health
S c nspector-Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - sewer/water connections -- 1t/ ?-Z -Q/�
- driveway permit- UJ 7-
Fire Department
Received- by Buil
ILi
JUL 3
---'s,--.. 's
Inspector
71 ,A%%l
Date
- - - '-,> - "✓�e Eana�naiuuea�l�. a` ._- llcr.;,:ac�uaefl3
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Nueber: Expires: Birthdate:
CS 005693- 01/13/1998 01/13/1954 .
Restricted' To. 00
DAVID A KINOREO
►� 40 MARBLERIDGE RD POBOX531
N ANDOVER, MA 01845
Restricted To: 00 17 6 5 0 ;
00 - None f t
14 - Masonry only f
16 - 1 12 Wily Holes
Failure to Possess a current edition of the
Massachusetts State Buiildiry Code '
is cause for revocation of this license.
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