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Home My WebLink AboutMiscellaneous - Suite 1020 0 N Location 4 S A ul dy`f dt S No. � Date HORTN TOWN OF NORTH ANDOVER Certificate of Occupancy $ 41 s� � `.• a Building/Frame Permit Fee $ UU ,SSAC MUSEt� Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ G TOTAL O " Building spector 1/-759 09/02i98 io:ae 78' W Div. Pu i Works Location i Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ / Building/Frame Permit Fee $ / Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ jT TOTAL Building Inspector 09/02/96 10:48 78,00 PAID Div. Public Works - ? D m y j ;7r. � ^. m N n � — - - � m e m a D M. > V, r z m m F T - N y z m D) w vF m w Z y�^ 1 m Gy m r; /�. 3 m Z I G J C ., x K m m z 1 m m 7 w ^ G K m Z N jF m m D A A Z .. m Z m R^1 N ©m Q r 7ri-� N Z t' � m se � Z e a > V, n m _ E 0 - r y z m m v Z y�^ m > Z A m Z I G ., K m m c ©m Q r 7ri-� Z t' ? m A 4 z-4 ' Z e > V, n m _ E - O - r y z m m v Z y�^ m > Z A m Z ., K m m c m m D A m D T ( ` Z VI 4 N ? m 'S Z Z _ m m ti n F m D O C j E D' �• a z x x Z M. %• N r � r z 0 X _ N L T. z S N 3 ©m Q r A CO) G � � O �n CO) Cl) CD CDCL O 'O Cr1 CZ = CA l J 'D cn CD c v O r� CD _ cn CD r, CD 0 CD O r� CD O CD C CCD y� O OCD y O cn 0 0 o CD � CD cCDD C c? mo o o d V! 2 w Q CL ti CD Co`a co) �aC 3 bw G ]' �%' m W n O� • �'� .dr r C T =rmaid Q y W CD N oma' o =m f C _ b m O i.� m � moi. s! O TI p N• n : I I W �� m •'• s :G a aoo~ CD CD H , o m .F N a!� o C, d y a d Q Q. CL H CD m coo �i IE ��C CO)qt -. CD mW: --0 CD <o 0 0 D 0 =r o , "b T � r► m o NCD CD " }� b o ^' is .i CO) d o CD CL .� Y a m O rO ~ p ' w G y x bw G ]' �%' m W n - ro x G Chi R r b CD CD =rl Q %,k V y 0 1�� A Ef-_ The Commonwealth of Massachusetts ( Department of Industrial Accidents Office 8//aresUff2 ens 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit IgN am a -sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the follow m* orkerscompensatio lices: o��t:omnanY name: N aD livl � TAAf, Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one years' imprisonment as well as civil penalties in the form of :t STOP WORK ORDER and a fine of S100.00 a day against 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 hereoX cgftify underAe pains and penalties S Print nine that the information provided above is true and correct Date d }� hone #P official use only do not write in this area to be completed by city or town official city or town: permit/license # [7 Building Department oLicensing Board C3 check if immediate response is required oselectmen's Office C]Health Department contact person: phone #; MOther (revised 7/95 PIA) ..' ✓1[e �O�))lgJyQ/7,�j�� /�aclLuaetGr I 'x.