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HomeMy WebLinkAboutBuilding Permit # 1/7/2016 BUILDING PERMIT ®FDS q- ®��S LEo / R•�� I TOWN OF NORTH ANDOVER � '• APPLICATION FOR PLAN EXAMINATION Perrmit No #: Date Received A�Rar�o�pe¢y�� �&S�cous�� Date Issued: IMPORTANT: Applicant must complete all items on this page � r r r, o,,� / r/ r ✓ / r ""'g r ! / r r l ! / r r/. r / //i, r I l 1 r r / 1/ ✓�/ / /I / � / , r r r 1 , t /D l / fJ ,r fr � � �� �/ �1/J/ �, r / , ,,,.r / r•. / r�rlJ / i�,r / //��/ % /I D � / �. ,/ 1 /� � �, � r,r / r r � r�i / � / 1/ ,�, ����If,�✓ill r� r� ,r, � / �,/r. /�Jl / ,err,// i./,..� r %l. /i / / �/ I r/! r r �(�/fr,r:,.,,, •�r f�� ,f,, 1/a r•, � � '( I�• I p,,v / r- r, / r1// /,f,,/riiii/. /// /r;/�1��/Lr, l r' 1 / I r>� t �,.�G/,/:.r fj,' r l + � (� r ' l 1 ri,. 4{�1 1+ail,',r„rrirre✓�:.���/./� r���//ii rsrr�Jij,� , /,r��R«i�nru �Mrlfl� r• - IYf , /��, r �. «r, � �' ,r 4 I,r•p,� r,-1�I« xa /rJ1!'///�Ji fD�H St01'IG;,U IS�rICt, r( 8' ,ir% / OI�? ' / l f ,,, ./,/ / /✓r//N „ � rrr,, l/11 y/� , / � % /% J)l� r�>�/ /,////rl/l1//�/r//�,�////r ,( ���,, ////,I//,e✓;•/,r-„ ,,,,, �/ ,. r o , / r r e, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg �4 Others: ❑ Demolition ❑ Other '�r rlSv i k & ,,;❑':Wetlands %; /1, � , a z /,u. .tic, ❑„ I r, r � r,, ! rr, rah, /. � ,., �/I�i6�•.rr. /.r //'./ ,.,,, �� /�6,,. / ,,. ;.// /,::., ,:. /� �. / -./ / / /rr ,/ ,,,.,. , i rrr (.r, /�,�/ n/+rii,,, ir/ %//�� /l',� 1/J r//.:ria /l,, ✓/rf /r / i,.-,; /, r// l� // 1 ,l� / ,> / r% .,. /r//❑rWat�.r/Sew_er�� ////� /,/, /,,,,,� �>/������r,�J��/l r�rrr/��r,rr,i/r �.,�,�, . , ;,/�,,/,/;. U:,,,s�r,,,�< ,>�/,,,,,�.. DESCRIPTION OF WORK TO BE PERF® IVIED: f V- SQA C P�t )`/h L h , 0/opt 7'D ” 1r Identification- Please Type or Print Clearly OWNER: Name: ret J i-@ rek Wkeyv+4 61 Phone: 'F? ` d>-;>G ? Address: I qb Pq,--qd&Y'1 >' AA oritractor Namer ony Ph / r r . - //✓' /�/ I, / ��./� /.,. , �.. r // /rii„, /..li / ,/,:,///. /�, /��r/ / ,. �//r��''�/'dl/����Yl'!��/��r�,�r%/k/Jf,... r /i /.//� iia // / ✓ /.., / I r / s„r l s,/%r oi,r(,,,.r1/n�rr�.(t��i/h!af�r��/� �i ,N�/ �✓/( , e�� ,1 / i// r/r/ 0 rr/• // �/ G I + � "� , �j� � ,1�,,, � .[. l r r r r r, r/, ✓ �/ / /, ,��rf / , r r r rrr / ri ! /r r ,.r/ ,,.. r r„ l, ✓ r 1. r,..... ,r L..✓�,//,// / /<...///, ..r.. r/r.,,.. .r L. II/��I. r. r. /, , r”I r /,.. ,, , Exp f/Date� w�,,. ., - ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE;BULDING PERMIT;$1200 PER$1000,00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ y o s o 0 FEE: $ � Check No.: Receipt No.: NOTE: Persons contracting with unregistered cont ctors do not have access to the guaranty fund � ignature_of Agdnt/Owner Signature of_contractor- j rim FORTH I own Ofd�' ... ', . An over ® •° "K � No. doom, T O - LAKE h ver, ass cOC.41C ewlcw 1' 7,9 R�1reo Smoak S U BOARD OF HEALTH Food/Kitchen rERMIT T L �D Septic System THIS CERTIFIES THAT ,,,,,�� BUILDING INSPECTOR ...:......... . . . ................. .....;il� .................................. 4f Foundation ... has permission to erect ......... . buildings on ... ............... . ......... !' ................................. Rough to be occupied as �............................ Chimney provided that the person accepting this per ' hall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMITl E IN 6 MONTHS ELECTRICAL INSPECTOR UNLESSTIOA S Rough 7Service ........................ .................................................... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. Federal lD#08-0408829 RISE Engineering RI Contractor Registration No 8188 MA Contractor Registration No 120979 A division of Thlelsch Engineering CT Contractor Reglstratlon No 920120 60 Shawmut,Canton,KA 02021 CONTRACT 339-502-5197 - ------ FAX 339-502-0345 Page 1 C� PROGRAM rroscaMNOA DaMCUlFrnrroaervas�+ams j� CMA-HES DESCcW�BELOWWcusroeo?xrnawaacns PHONE C Bradford Wakeman " (508)328-4630 07/10/2015 418421 00002 Ull 140 Academy Road Q 140 Academy Road 0 cn North Andover,MA 01845 North Andover,MA 01845 OB DESCRIPTION PHASE ONE-Proposal for this calendar year. $0.00 AIR SEALING:Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthfid level of air exchange and indoor air quality.Materials to be used to seal your home can include caulks,foams and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.)This will require(8)working hours. A reduction in cubic feet per minute(cfm)of air infiltration will occur,but the actual number of cfm is not guaranteed. At the completion of the weatherization work,and at no additional cost to the homeowner,a final blower door and/or combustion safety analysis will be conducted by the sub-contractor to ensure the safety ofthe indoor air quality. $680.00 AIR SEALING ADDER: (4)working hours. $340.00 ATTIC FLAT.Provide labor and materials to install an 8"layer of R-28 Class 1 Cellulose added to(1440)square feet of floored attic space. $2,592.00 DAMMING:Provide labor and materials to install a 12"layer of R-38 un&ced fiberglass batts to(38)square feet for damming purposes. $77.90 ATTIC FLAT:Provide labor and materials to install a 10"layer of R-35 Class I Cellulose added to(176)square feet of open attic space. $258.72 COMMON WALL:Provide labor and materials to install R-19 unfixed fiberglass to 72 square feet of common wall. Then install 2"rigid board insulation that meets the sections R-316.5.4 and 316.6 requirements of building code. Seal all seams with FSK tape. $28224 CRAWLSPACE:Provide labor and materials to install(740)square feet of 6 ml polyethylene over open ground in designated cmMspacelearthen basement areas. $569.80 RISE Engineering will apply all applicable,eligible incentives to this contract You will only be billed the Net amount Currently,for eligible measures,Columbia Gas offers 750/a incentive,not to exceed$2,000 per calender year,and an incentive of 100%for the Air Sealing measures up to the first$680 and an additional$340 if savings are justified by the auditor. For the safety and health of your home's indoor air quality,we will be conducting a blower door diagnostic of the available air flow in your home both before the work is begun,and after the weatherization work is complete.We will also conduct a full assessment of the combustion safety of your heating system and water beater.This has a value of$90 and is at no cost to you. Total allowable weatherization incentive is$3,110. $90.00 i / Federal ID#05-0405628 RISE Engineering RI Contractor Registration No 8,186 MA ContractorRegleiration No 120879 A division of ThEetsch Engineering CT Contractor Registration No 620120 60 Shawmat,Cantos,MA 02021 339-502-5197 FAX 339-502-6345 CONTRACT Page 2 PROGRAM TMCONTRACT reENTERED INIO BETWEEN RISE CMA-HES R=N8G&00jM C USTOMER FOR WORK AS -Vaffb-017— PHONE ION CUENT# WGIRUKDER Bradford Wakeman (508)328-4630 07/10/2015 418421 00002 140 Academy Road 140 Academy Road North Andover,MA 01845 North Andover,MA 01845 JOB DESCRIPTION Total: $4,890.66 Program Incentive: $3,020.01 Customer Total: $1,870.65 WE AOM HEREBYTO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***One Thousand Eight Hundred Seventy&651100 Dollars $1,870.65 ELFNALttiSPECfiONAND APPROVAL BY R6E ENOIXELEtINO.CUSTONERAIATEESTOR®OT ANOUNi OUB 0 FULL riTFABBTOF SX WSL BB CNAROED MONnLLY ON ANY BALANCEAFTBt 700AY&6EE REVBteE FORULPORTANTINFORYAnON ON OUARANiEF99�RN11Ti8OF RECISON.BCNEOU aAND ODNTRACTORREQUiTRAT10N. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES Michael T dean(Aug 21.2015) Signature: ��4,e OA e B. WRke�`'a" Bradford B.Wakeman(Ja117.2015) Email: bwakeman@williams.edu NOTE:Me CONTRACT MAY SeV&MRAVM BY USIF NOT EXECUTED WRNIN 0117EOFAOCEPTANCEACCEPTrva '.. 8A C�TO�RYFTO UBARBtff.AAEABOW�EPrED.YA REOAMOADT'O�DOTVVORK ,3O DAYS. AS SPEC6IED.PAYIfENTWLLee NAOEAB OUTLINEDABOVB OWNER AUTHORIZATION FORM Bradford Wakeman 1, , (Owner's Name) owner of the property located at 140 Academy Road, North Andover MA 01845 (Property Address) 140 Academy Road, North Andover MA 01845 (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to ad on my behalf to obtain a building permit and to perform work on my property. ee gnatur Date 1!4/2016 Preview:Certificates of Insurance ACaR0 11/04104122016016 Y) ° CERTIFICATE OF LIABILITY INSURANCE DATi ��- THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Ez1: No. Automatic Data Processing Insurance Agency,Inc. PROBE x AtC.No. (Ar C. 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC I1 INSURERA: NorGUARD Insurance Company 31470 INSURED INSURER B: POLAR BEAR INSULATION CO INC INSURER C: PO BOX 958 Andover,MA 01810 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 429703 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR TYPE OF INSURANCE LTR /NSD VJVD POLICY NUMBER tM&DDIYYYY) (1d VDDYYYYYj EXP I LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S _UTrr1_1GE 10 HEI, CL•fr.lb IJAOE ❑OCCUR ,'REMISES IEa u_currenz.•! S LIED EXP lima.one I, so! PERSONAL S ADA'INJURY 5 GEN LAGGREGAT E UHI T APPLIES PER: GENERAL AGGREGAT E S RG POLIC'f'❑JPEG7 F-1 LOC PROWCFS CGLIP;CI'AGG 5 OFFER: S AUTOMOBILE LIABILITY IE .1 IN SIN L 11:111 Ea a d nt{ ANY AU TO BODILYIKJURY IT',W_-111 S ALL GYrNED SCHEDULED BODILY INJURY/Per az dew S '. AUTOS AUTOS NON O'NNED 'iV't Y M:.0 S HIREDAUTOS AUTOS fPc'r.-iadrYdl S UMBRELLALWB GCCUR EACH OCCURRENCE EXCESS LIAR CV•0.{SLLADE AGGREGATE OLD I I RETENTIONS S WORKERS COMPENSATION XH- STAIUIE EFt AND EMPLOYERS'LIABILITY Y r N JY 14iCPIilE1 OR�{'AHTI:EH•EXECUTIt'E E.L.EACH ACCIDENT 5 1.000.000 '. A olJFHCER�IJEMBEREXGLUDED? �NIA N POWC772258 0110112016 0110112017 (Mandatory in NH) E.L.DISEASE EAEMPLOYE 1.000.000 11 fes.d-be r,ndv 1,000,000 UESCRIPFICN OF OPERA HOES bU., El DISEASE POLICY UF.IIT S DESCRIPTION OF OPERATIONS 1 LOCATIONS!VEHICLES(ACORO 101.Additional Remarks Schedule.may be aluched ii more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN '.. Theitsch Engineering,Inc. ACCORDANCE WITH THE POLICY PROVISIONS. 195 Frances Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE (... )4. i A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD POLABEA-01 JONEILL CERTIFICATE F LIABILITY INSURANCE DATE(MWDD/YYY`) 1/6/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Durso&Jankowski Insurance Agency PHONE 11 Saunders Street g y A/c No EXt):-(978)688-7000 - FAX Nod_(978)688-7001 - - North Andover,MA 01845 ADDRESS: -- —-- INSURER(S)AFFORDING COVERAGE NAIC 9 INSURER A:Nautilus Insurance CO. 117370 INSURED INSURER B:Safety Insurance Company 33618 Polar Bear Insulation Co.Inc. INSURER C _- Peter Leblanc&Steven Leblanc P 0 Box 958 INSURER D: Andover,MA 01810 -INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. �SUER POLICY EFF POLICY EXP INR TYPE OF INSURANCE IVSD W BR POLICY NUMBER MM/DD MM/DD I LIMITS A X !;COMMERCIAL GENERAL LIABILITY (EACH OCCURRENCE__ $ 1,000,000 �y� f DAMAGETO WENTED —I CLAIMS-MADE I�OCCUR ( NN538691 1 03/24/2015103/24/2016 PREMISES(Ea occurrence) 50,000 MED EXP(Any one person) $ 5,000 I � PERSONAL 8 ADV INJURY $ 1,000,000 I GEN'L AGGREGATE LIMIT APPLIES PER: � L GENERAL AGGREGATE r$ 2,000,000 X ( POLICY PRO PRODUCTS-COMP/OP AGG $ 1,000,000 ��JECT �LOC - i OTHER: I - --— - $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident)_— -_--_ Is 1,000,000 B ANY AUTO X2100926 I01/04/2016 01/04/2017 BODILY INJURY(Per person) $ -- -- I�ALL OWNED y SCHEDULED BODILY INJURY(Per accident) $ AUTOS '_I AUTOS HIRED AUTOS y 1 NON rPFCOPERWDAMAGE- -OWNED $ X ;AUTOS er accident __-_ _ I $ UMBRELLA LU\B' X OCCUR j I EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMSTVIADE� IAN019284 ; 03/24/2015,03/24/2016 AGGREGATE__ $ -- -- DED RETENTION$ i _ $ !, PER OERH WORKERS COMPENSATION —I — STATUTE AND EMPLOYERS'LIABILITY Y/N E L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑'N/A j - - 1 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under f f j E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS below i j I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Insulation Work-Mineral Insulation Work-Mineral;Additional insured for general liability per blanket additional insured endorsement with respects to work performed on their behalf by the above insured is Thielsch Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Thielsch Engineering Columbia Gas ACCORDANCE WITH THE POLICY PROVISIONS. 195 Francis Ave Cranston,RI 02910 AUTHORIZED REPRESENTATIVE n inoo oni n Amon PnonnoA-rvnnr All"-k+- ,...,..� The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass gov/dia 1Vorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE RLEID WITH THE PERMITTING AUTHORTIY_ Applicant information _ Please Print Leeib)v NBIriC(Business/Organization/Individual): L/t7 j/A t +)Y rt !i` iA 5urn; /�i\�14 ('0 Address: City/State/Zip: , t<-,-� {— X1'1 ld`/ Phone#: %7 i�' �' TP Are you an employer?Check the appropriate box: Type of project(require: l.afl apo a employer with (full and/or part-time),* 7_ ❑New construction 20 I am a sole proprietor or partnership and have no employees working for me in g_ Remodeling any capacity.[No workers'comp.insuaance required..] t 9_ ❑DunoIition 3.01 am a bomeoa ner doing all work mysclt:[No workers'comp.insurance required.) 10®Building addition 4-[]]am a homeowner and will be hiring contractors to conduct all work on my property- 1 will easrae that all contractors other have workers'compensation insurance or are sole I LE]Electrical repairs or additions prnprictors with no employees_ 12.[]Plumbing repairs or additions 5�I am a general contractor and I have bired the sub-conamaors listed on the attached sheet These sub-contractors have employees and have workers'coag.instaaocct 13.�Roof repairs 6.❑We arc a corporation and its otliws have exercised their right ofucmption per MGL c. 14.®Other . 152,¢1(4)�and we have no employees.[No workers'comp.insurance required.] '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 bine outside contractors must submit a new affidavit indicating such lContractors that check this box must attached an additional sheet showing the name of the sub-oomractors.and state whether or not triose entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. /am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site Information. y Insurance Company Name: J /(7 ;1�� v��t Policy#or Self-ins.Lic.#: Expiration Date: �/ /��O lob Site Address: 1 l b 19,^Ct d Z°WLy 1, City/State/Zip: /7.Y9h\ d-e f Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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 file of up to$250.00 a Jay against the violator-A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance ;overage verification. t do hereby certify under the pains and penaldes of perjury that the information provided above is true and correct 'z�rtature: �� ��� //� -��a� (l _ --- - Date- f�� 'hone#: 1;:7—".2.2 —j r,3 e Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1_Board of Health 2-Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector 6-Other Contact Person: Phone#: eusIteO► IceofCone'�,ffaxrs 5170 10 parkl'laza- Sui s 02116 Boston, assacht�s gytion ome g�,provem actor � ra eYlt�:OII1 ', RpBltion_ 102728 OBA Tr* 2 -_- expiration: 7t212Q18 pOLAR BEAR INSULATION CO- = = - _- Vincent LeBlanc --- P�Q, gOX95$ __ rkreasoaforcliange. ANDOVER, MA 09 81 Updaxe Address and MMMimp►vent ❑Lost Card ;—� Address Renewal ppgCAi Sa 5fllUFo4(Il4 G1a12i6 i nfis • �O.�CC$t75�L•an-i:C! �C�«I{sz";E1fCS est"3�••_ �,��=c tSa�cFle,ri�uy:ers t olspryr�My�,g�ppr�:�I�^i ,?LTIER A LEBLANC 2 EAST POE STREET Plaistow NR 03865 0412812018 :ann,f�issxone: