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HomeMy WebLinkAboutMiscellaneous - 1530 Forest Street (2) 1530 FOREST STREET 210/105.A-0025-0000.0 1 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Mark & Michelle Charpentier Property Address: 1530 Forest Street Ext. Policy Number: HP3077190 Date/Cause of Loss: 3/10/2015, Water/Ice Dams File or Claim Number: 31922-R Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Ryan Werner On this date, I caused copies of this Notice to be sent to the p rsons named above at the addresses indicated above by First Class Mail. Sig t rfe and Date ANDERSON ADJ STMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Date J ... .......... ' 1028 0ORT/y 3��,..•�;.:'tiaoL TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING CHU This certifies that. .e..k�.... .................� .............-�:C'C ... has permission to perform v.... ..`1.2.........c ......... ` . ................................ Pplumbing in the buildings of....('51 C Jaz �n� ��. g g ..... ........ ........................................................... at....., �-�... .QS `k.. ....... North Andover, Mass. Fee �...".......Lic. No. 2.� .!....1 . .........L ....BI................................................ {�Z34� PLUMBING INSPECTOR Check# �`�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WYORK CITY MA DATE ( PERMIT# Z JOBSITE ADDRESS U �—.r�s Y�-� �� I OWNERS NAME OWNER ADDRESS + TEL[ _ F TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL EP RESIDENTIAL PRINT i CLEARLY NEW: °] RENOVATION: REPLACEMENT: 01 PLANS SUBMITTED: YES® NO FJ FIXTURES-1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM t DEDICATED WATER RECYCLE SYSTEM _ t DISHWASHER __.. ! DRINKING FOUNTAIN __I FOOD DISPOSER FLOOR/AREA DRAIN _.__ — I _._l .__( --.J -.__J _I __ INTERCEPTOR(INTERIOR) _+ _----- —! __ _I T._ ..__..__.1 I _..__( ____1 _ _ __..___..! -------- ___. 1 ( ! .__...__._i KITCHEN SINK .---- LAVATORY ROOF DRAIN �___ 1 _.___1 __—I ______I __._._I __..__I .-.___ I ._._ _._..__. _.._.._! ..... ► ____J ! m_—._.6 SHOWER STALL _I ._._._1 _ __-_I _._ SERVICE/MOP SINK _4 ._.J _. _! _—.__i ____I _.__l _—_ f _._IL—__I TOILET UPMAL WASHING MACHINE CONNECTION I ! WATER HEATER ALL TYPES -.' -� - WATER PIPING OTHER - _ IN50RANCE COVERAGE: 1 have a current liability insurance policy or its substan ' equivalent which meets the requirements of MGL Ch.142. YES O!-10 IF YOU CHECKED YES,PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY r 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 a AGENT IC` SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application true and accurate /th st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will bei co p' hall erti e t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER' AME�� t tem LICENSE# f 3 7 SIG TUR ! IMP JP i CORPORATION MI# i PARTNERSHIP[]# L C - - COMPANY — .COMPANY NAME� S_ t 1 /rN ADDRESS CITY STATE ZIP Gl�` ----�� TEL —� ._ �r � !cl� !I �7 5;r 77.7— 2 Li FAX _._.. CELL '7�r7(6:._-._ EMAIL i r • `Y Informati®n and Instructi®ns Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees, i Pursuant to this statute,an employee is defined as"....every person in the service of another under any contract ofhire,- express or implied,oral or written" An employer is defined as"an individual,partnership,association,corporation or other 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 individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building 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 compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary;supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance, Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required. Do advised that this affidavit maybe submitted to the Department of.Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of —� Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance 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 Investigations has to contact you regarding the applicant. Please be-sure to fill in the permithicense number whichwill 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(ifnecessary)and under"Job Site Address"the applicant should write"all 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 future 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 venture (i.e.a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank 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: Tho GoozjwcaIthofMassacRvsPtEs .Department of izidu*1al,Accndmts OfRee ofX]nvesligations 600 Wasbiagton Sfro,�t Bost¢u}MA 02111 TO,#617-7.27-4900 oyd 406 or 1-877:MASS FB Revised 5-26-05 Fax 0 617-727-7749 wWWaxtass,gQvfdia ..� ----- COMMONWE�►LT'H OF MASS ►CHIJSF. e UMBERSB � SF ITTERS ISSUES TI{E "pbLLOW IN� L'1 CEN:SE LIGE: SSDJOURNEYMAN pL,.UMBER }> - r a UES . MARK, T JACQ 12 AVER`I LL R AO Y_ e ; 4I: ILE SON MA 1949-13 2i4g8 05/0 /16. 223964 i ONWEaLTHw� 0 MSAHl1SEns � �OWIM • , • o • • SF ITTERs pL"UMDl- ISSUES ;E''F OLLOW 1'fiIG PLMgER A MAST L I GENSE I AS .ccs Q "r JAQ w ; I C UE5 .:T K.. 12 AVERtliL pp; . MA o 949 3 2..:. 65 L ON 2 39 1.2:39 fl I I �., OP ID: PS DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE k. / 03/04/2015 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 Pete Sullivan Foster Sullivan Insurance NAME:PHONE 978-686-2266 a/c No;978-686-6410 163 Main St. (AIC,No Ext North Andover,MA 01845 E-MAIL SS:psullivan@fostersullivangroup.com 9 Stephen Sullivan PRODUCER CUSTOMER ID#:JACQU-4 INSURER(S)AFFORDING COVERAGE NAIC# INSURED Jacques Plumbing&Heating INSURER A:MERCHANTS INSURANCE GROUP 12775 Mark&Christine Jacques INSURER B:THE HANOVER INSURANCE COMPANY 22292 12 Averill Road Middleton,MA 01949 INsuRER c INSURER D: 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. INSR TYPE OF INSURANCE EXP DD U R POLICY NUMBER MMIDIDYY MMILDDY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY BOP9099826 09/01/2014 09/01/2015 PREMISES Ea occurrence $ 500,00 CLAIMS-MADE F_x�OCCUR MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 A ANY AUTO MCA7015294 01/04/2015 01/04/2016 (Ea accident) '000,000 r r- BODILY INJURY(Per person) $ X ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (PER ACCIDENT) $ X NON-OWNED AUTOS $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,00 A CUP9142872 09/01/2014 09/01/2015 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- X OTH- AND EMPLOYERS'LIABILITY TORY LIMITSER B ANY PROPRIETOR/PARTNER/EXECUTIVE Y I N WHN8404471 09/01/2014 09/01/2015 E.L.EACH ACCIDENT $ 500,00 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) REFERENCE - JOB @ 15-30 FOREST ST. EXTENSION CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. ATTN.-JIM HURLEY FAX 978-688-9542 AUTHORIZED REPRESENTATIVE 1600 OSGOOD STREET NORTH ANDOVER,MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Date.3 . .`�11<.......... 40RT#t TOWN OF NORTH ANDOVER o3a ' PERMIT FOR WIRING ,SS�CHUS�t This certifies that )�..`' (� ( . w UGQhas permission to performN.., ............... ....................... wiring in the building of......... ...... ................../L"............................................................ sl. ...3: (.. ... E...L..E.PrthAndover,Mas . --- � . Fe .Lic.No. ....... ...... Check# (9q TRICAL INSPECTOR 1314. 4 Official Use Only Permit No. t >. �eparyfinent o��ere�ervicee Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co; (AVEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INF, RMATIOA9 Dater ,, ,, . i �- City or Town of: 4s A X oat-✓- 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) / 3^nC2 r e 5 Owner or Tenant MA - K CG r 2en,z L ;e,. Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Buildin P g Utili Authorization No. ty 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 Na a of Proposed Electrical Work: 7 ; i"a„e s--/, � D r Completion o the followingtable may be waived by the Inspector of Wires. No.o No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above n- 17F.-ol Emergency17F.-o Lighting rnd. 0 grnd. BattervUnits No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiatin Devices No:of Ranges No.of Air Cond. Tons No.No.of Alerting Devices No.of Waste Disposers Heat Pumpumber ons o,of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Muni cepa ❑ Other Cysonnection No.of Dryers Heating Appliances KW Security ystt cress or Equivalent No.o ea KW No.of o.o Data Wiring: Heaters Sivns Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP a ecommumcationswin-ng: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electpcal 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 W- BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: le, k/ LIC.NO.c-����j� Licensee: t Signature _LIC.NO.: (If applicable,enter��I" the license ms ber line Bus.Tet.NO.' � 70 7 Address: W! Alt.Tel.No.. Z,-, *Per M.G.L.c. 147,s.57-61,securi work requires Department of Public Safety"S"License: Lic.No.• i o 1 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)El owner M owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ .i Fold,Then Detach Along All Perforations COMMONWEALTH OF MASSACHUSETTS. v E LE CTR I'C 17 N S 1 v SSUES.TR E FOLLOWING L'I CENSE AS...A REG 'J{fURNEYMAN: ELECTR I C11 AN `` rr DE�tAYNE R P SULL I AN 9 -`4 i 18 BAYBERRY RD U, - � �U, ! DANDERS �:.,. MA: 01923-1536.... 34149 Es:_:>:>> 7%31;!<] '>; ` '_ 8 95 9 ...... . ... i ti- Fold,Then Detach Along All Perforations COMMONWEALTH OF MA$SM"USETT 0 0 o o f BOAR1 —F ` }} 1 Ea XTR'I C I ANS f ISSUES THE FOLLOWING L;I CENSE AS A i,># RE I5TERED MASTER ftECTR l:C 1 AN`. f a DEWAYNE SULLIVAN AND SON Z ,0 DEWAYNE R F 5UU I VAN .: W �. 18 BAYBERRY RD z sR N w DANVERS Mtn 01923-1539 p 14405 A. 07/31/:1695892ITIMIR ' - .. I r'� Date.f�/.7 //. ...... .. NORTH =Oya..ao ,e who O m TOWN OF NORTH ANDOVER 41 '4 PERMIT FOR GAS INSTALLATION ' h �wS SwC MUSE�4 This certifies that . !?. ./.�•1�. . . 6/ �f. . ,/�i�,t.!!/C.,1.4'. has permission for gas installation t.��:�"'.'��. . . . . . . . . in the buildings of . . . . . . . . at i4� `l. � r ?o. . . . . . . . . North/ndover, Mia/ss. a4 Fee :S v Lic. No. G% . f? rf'f4 . GAS INSPECTOR Check#. 7- 7852 ? 8552 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING CITYITOWN: .. STATE:MA APPLICATION DATE:' ATE JOB ADDRESS: f 5:. o Ft T !�j L OCCUPANCY TYPE: COMMERCIAL RESIDENTIAL PLANS SUBMITTED: YES❑ NO E] NEWeA LTERATIOND REPLACEMENTS REMOVALIDEMOLITION[] t NATURAL & LIQUEFIED PF;I•ROLF,UM GAS: PIPING -EQUIPMENT-APPLIANCES-SYSTEMS Z ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS AIR ROTATION UNIT ( ._. FURNACE: ALL TYPES ! TEMP HEATING EQUIPMENTi _,. . BOILER:ALL TYPES GAS PIPING --""" THERMAL OXIDIZER i -'--- BOOSTER ---- GENERATOR STATIONARY ENGINE TURBINE _ - BROILER i"" ILLUMINATING APPLIANCE ' UNIT HEATER BURNER: ALL TYPES " i INCINERATOR �_..._"� WATER HEATER: ALL TYPES CO-GENERATION UNIT --_..f INDUSTRIAL AIR HANDLER =- -- EQUIPMENT OVER 12,500MBH _.._... COFFEE ROASTER __r-^I INFRARED HEATER ^_ ! !OTHER NOT LISTEDZ T COOK APPLIANCE HOUSEHOLD 1 KILN 1 GLORY HOLE 1 CRUCIBLE COOK APPLIANCE COMMERCIAL - LABORATORY COCKS - -- '---' ------- _ DECORATIVE APPLIANCE MAKEUP AIR UNIT DIRECT VENT APPLIANCE --- MECHANICAL EXHAUST EQUIPMENT _ DRYER: ALL TYPES ...__.^ OVEN: ALL TYPES "�`"-'1 r-"-""-- ----"-----�� i--- FIREPLACE:VENTED/UNVENTED - POOL HEATER - FRYOLATOR ! ROOF TOP UNIT i--"--- ----"i FUEL CELL _._1.11 ROOM HEATER-VENTEDNENTLESS ? -1 L_. - PLIIAIBING/GAS FT TING 1I101 INFORMATION - CHECK ONE ONLY ._:.-1 l+ . :: . C.t. 4DDRESS:...Cr ..: L�?Ql��.S7, ._ tt � f_/ _ orporation Business# NAME: l l- �Tl I I Partnership Business# - CfTY. .._�J,.Afhb(11>'J✓i2 STATE::MA' D-,I EILLC Business# t. 3��� n c�j� TEL: C1:7�I�.�'�1. �-33 FAX: EMAIL:r,. .:vpti� C� N DDBA/Unincorporated NAME OF LICENSED PLUMBER I GAS FITTER: J FP v INSURAN(.'E('OVERAGI+ have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESP:J'NO If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. LenA liabilityinsurance policy Other type of indemnity❑ Bond P Y 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 Signature of Owner or Owner's Agent OWNER AGENT OWNER'S NAME: ::..; TEL: m._, ._ FAX , I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. FFee: OF'FIC'E IISE ONLY) Typc of license: Permit Plumber ❑Gasfitter // aster Journeyman n ur of Licensed Plumber/Gas Fitter /Ia O ❑ Y ZSf/ ❑UndilutedLP Installer License Number: :-•,--- Limited LP Installer The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 4 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Plea/se Print Legibly Name (Business/Organization/Individual):_;:a xe/yt? 2dy/ 1%xgx a /I/�A% Ad '—` dress: City/State/Zip: /Ih7' Vii' lVl,,� hone Are you an employer?Check the appropriate box: Type of project(required): 1.92 l am a employer with r,2 6— 'fz' 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance.$ 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 131-1 Other comp.insurance required.] *Any applicant that checks box 41 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 6;t( &/-0/ Policy#or Self-ins.Lic.#: ` (� G y �<, Expiration Date: O Job Site Address: 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date / - 7 2O// Phone#: 3 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License#� Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• QMMONWEALTH OF MASSACNU$ETTS REt�ISTERED AS PLUMBIN X-E! ISSUES THIS LICENSE TO 1 FFREY P RUTNICK CA G L AH A!d_,A I:R CO ND I TO G O'U T H S- ME }�UE1 MA 01=8�+4��45 2$40 0 /0'1/12 w5248 COMMONWEALTH OF MASSACMUETI DIVISION OF PROFESSIONAL LICENSURE �IGENSED AS A MASTER:PLUM Elt ISSUES-THIS LICENSE TO JEFFREY P`,HUTNICK 6 PLYM';U'UTH ST METFiUEN MA 01.1344 1512 "o-5/01/1234 w -y s COMMONWEALTH OF MASSACLU i LICENSED AS A JOURNEYA PL �71 ISSUEST}iIS!ICENSE TO, # x UFfREY, vi ICK ST a. METH MA -m 5"N �1�.$1 b5/01/12 - TF/►OR BUILDING PERMIT oF�r4OR bgti TOWN OF NORTH ANDOVER c APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �oAATlO P�`y.(5 // � �SSACHUS�� Date Issued: / Q� IMPORTANT:Applicant must complete all items on this page "LOCATION 9=0 --e. Pri 'PROPERTY,OWNER " Print MAP NO:: PARQEL6 ZONING DISTRICT: 1-listoric.District yes no Machine.Sho-p Village yes no 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 Others: Demolition Other Septic Well Floodplain Wetlands Waters ed District j Water/Sewer DESCRIPTION OF WORK TO BE PREFORMED: i Identification Please Type or Print Clearly) OWNER: Name: d, 4-1 s pa a /(n Phone:c/ Address: d �7-� Lo Q_W a CONTRACTOR Name: ew � � Phone: ,5w }-- Address: '3 r,, 7; Supervisor's Construction License: t �/ } exp. Date: �le , Irl.) I Home lmprovernen#=License: "' Exp. Date- ARCH ITECT/ENGI NEER ate:ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ t 729' c 60 FEE: $ �7 Check No.: Q(!0 0 Receipt No.: �G 2 NOTE: Persons contracting with unregistered contractors do not have access to the -uara ty fun �ignature of.Agent/Owner �` Signature ofiPeontractor . . �' _ „ Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And II Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building_Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require signofffrom Fire Department prior to issuance of Bldg Permit d In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded.at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use) i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Plans Submitted Plans Waived Certified Plot Plan Stamped Plans I TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature s I COMMENTS 9 Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street flRl= DEPARTMENT Temp Dur> pster on site yes no located:at 124 MaiwStree# Fire Department si nature/date - 9 COMMENTS t s. / _-1 Location .�5�.3 U � ��� Y/ s No. 3>23 Date TOWN OF NORTH ANDOVER P Certificate of Occupancy $ 3•�s'•^°''•tom Building/Frame/Frame Permit Fee $ Z`7 — s+cMust 9 Foundation Permit Fee $ Other Permit Fee $ ` . TOTAL $ Check # 2 6 2 ° /building Inspector RightFax C2-2 11/11/2008 4:33: 13 AM PAGE 3/003 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(MM%DD\YY) 11-11-08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE TARPEY INS GROUP INC HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 442 WATER ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE WAKEFIELD,MA 018804667 COMPANY 27TLY A TRAVELERS INDEMNITY COMPANY INSURED COMPANY B BATEMAN PAUL DBA FIREPLACE SYSTEMS COMPANY 37-39 WEST MAIN ST,SUITE 4 C GEORGETOWN,MA 01833 COMPANY D COVERAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWffMTANDFNO 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 HERON 6 SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLKIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM\DD\YY) DATE LIMITS GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL PRODUCTS-COMP/OP AGO. $ CLAIMS MADE OCCUR. PERSONAL 88 ADV.INJURY $ OWNER'S Iib CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Anyone fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Per Person) $ SCHEDULE AUTOS BODILY INJURY(Per Accident) $ HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYEWS LIABILITY U191-98991-708-08 10-29-08 10-29-09 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 100,000 PARTNERSIEXECUTIVE INCL DISEASE-POLICY LIMIT $ 500,000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIRESTRICTiONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CFR71FICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE POR BATE MAN PAUL. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF NORTH ANDOVER EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT 1600 OSGOOD STREET FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY RIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. NORTH ANDOVER,MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25-5(3/93) Charles J Clark J FI�EPLACE Suite 4 Main St. Phone:Fax: 978-352-3824 SYSTEMSGeorgetown,MA 01833 Web: www.fireplacesystems.net "Your One Stop Fireplace Shop!" Invoice Bill To: Date Invoice # John Biggio 10/9/2008 355223 65 Stone Cleave Road Boxford, MA 01921 978-887-5916 Stock# Description Qty Unit Price Total I2400M Medium Wood Insert Body Only 1,785.00 1,785.00T 850-151 Black Door for I2400M&F3IOOL 186.00 186.00T 140-911 Faceplate And Trim Reg Black 211.00 21 LOOT I2100/12400 142-917 Fan I2100/12400 Black 357.00 357.00T 948-625 Liner Flex Kit 5.5 in. X 25' S.S. 647.00 647.00T 948-412/P Adaptor Flue Offset Adjust 6 in. 91.00 91.00T Limestone Limestone piece 611/2" x 24" 275.00 275.00T 00 1-Installati... Installation, Freight, &Delivery 600.00 600.00 MISCELLA... Chimney pointing as discussed. 400.00 400.00 2,364.80 Deposit Subtotal $4,552.00 2,364.80 Upon Completion Sales Tax 5.0% $177.60 Total $4,729.60 Payments/Credits $-2,364.80 Balance Due $29364.80 Board of Building Regulations and Standards t One Ashburton Place - Room 1301 Boston, Massachusetts 02108 Home Improvement Contractor Registration Registration: 158828 Tvpe: DBA Expiration: 3/5/2010 Tt# 264843 FIREPLACE SYSTEMS PAUL BATEMAN 37 WEST MAIN ST GEORGETOWN, MA 01833 Update Address and return card.Mark reason for change. Address 0 Renewal [—I Employment ❑ Lost Card DRS-CAI 0 s0%i-07/07-PC8-1N � ,/!rc tionr�xnnncrrlt�. u��.l�asarli.•a;f•l�s � X Board of Building Regulations and Standards ' r . License or registration valid for individul use only tick HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: h ! Registration: 158828 Board of Building Regulations and Standards One Ashburton Place Rm 1301 ;> Expiration: 3/5/2010 Tr# 264843 Boston,Ma.02108 3 Type: DBA FIREPLACE SYSTEMS PAUL BATEMAN 37 WEST MAIN ST GEORGETOWN,MA 01833 Administrator Not valid without signature lassachu,ctts- ikpa tmcnt of Public S111*C1% Boar(I ni'Buiidini, Rc.ulatiun.and Standartls• Construction Supervisor.Specialty License License: CS SL 100449 - -- Restricted to: SF j PAUL BATEMAN 40 MAYFLOWER DRIVE ' WENHAM, MA 01984 Expiration 6/10/2012 < iai�ii �i nr Tri: 100449 A ch S 3 Z O O (�7 ' mn y.f�D m �N O N p- O�fII N ■M■ G) a 0,2 CD 27 N m�o o� ID `p WDo 9A O ID t7 Q' N i N m /Iwo 3 O < 7 Q) �. CD ZD__, :3 SR8 :03) C "a (D D m 00 m ___ r ----------------------------- --------------- r LISTED FACTORY BUILT FIREPLACE INSERT DO NOT REMOVE THIS LABEL MODELCERTIFIED FOR USE INCANADAANDU.SA.�WGENCY' CAUTION 11 El El El El 0 m , TESTED TO:UL a 0 246 F Jan Feb Mar Apr May June X c urs TESTED TO:ULCS828A31UL-14821UL•737 KEPLI,LE Paoouca V � Z REPORT NO.:2195-03.2 UJ U F -.ml..,,e.....s THE 12400M MEETS UL-737 STANDARD FOR FIREPLACE STOVES WHEN A FIRESCREEN IS PROVIDED. }= Cl �INSTALLANDUSE ONLY INACCORDANCEWRH THEMANUFACTURER'S INSTALLATIONAND OPERATING INSTRUCTIONS.INSTALLAND USEONLY IN MASONRY ! ZZ;6WQ-CJ FIREPLACE OR FACTORY BUILT FIREPLACE.CONTACT LOCAL BUILDING OR FIRE OFFICIALS ABOUT RESTRICTIONS AND INSTALLATION INSPECTION IN j 0 LU>.?Q LL LU 2007 YOUR AREA. a a MINIMUM CLEARANCES TO COMBUSTIBLE MATERIALS(MEASURED FROM INSERT BODY) t7� Z Z U D:Z m W 0 C4 ADJACENT SIDEWALL A)11 in 1280 mm § INSTALL ONLY ON A NON-COMBUSTIBLE HEARTH RAISED(F)0.5111113MM ABOVE AN L C� W O O 6 rn Uj C 2 Q? 2008 yt 3 MANTLE B)20 in1508 mm 3 `� ADJACENTCOMBUSTIBLE FLOOR.COMBUSTIBLE FLOOR MUSTBE PROTECTED BY NON- V)I-F zm G TOP FACING C)12 in 1305 mm Y)Y COMBUSTIBLE MATERIAL EXTENDING(E)18 IN/457 MM TO FRONTAND(G)81N12D5MM HOT WHILE IN OPERATION WL)0 y oz .SIDE FACING D)8 in 1200 mm 9 TO SIDES FROM FUEL DOOR.0.5'FLOOR PROTECTION NEEDS TO BE WITH k�.84. DO NOT TOUCH.KEEP CHILDREN, Q W U m y LL ¢f 2009 ❑ N CLOTHING AND FURNITURE AWAY. H F 2 g m COMPONENTS REQUIRED FORINSTALLATmN: 6IN 1150MM STAINLESS STEEL LINER. CONTACT MAY CAUSE SKIN BURNS. U)�W-1 LLIZ U OPTIONAL COMPONENT.FAN 1142617),ELECTRICAL RATING:VOLTS 115,60 HZ,0.6 AMPS,SCREEN DOOR 1840.102) READ ABOVE INSTRUCTIONS. c d 0 1 a DANGER:RISK OF ELECTRIC SHOCK.DISCONNECT POWER BEFORE SERVICING UNIT,DO NOT ROUTE POWER CORD UNDER OR IN FRONT OF APPLIANCE DO NOT CONNECT THIS UNITTO A CHIMNEY FLUE SERVICING ANOTHER APPLIANCE.DO NOT REMOVE BRICKS OR MORTAR IN MASONRY FIREPLACE FOR USE WITH SOLID WOOD FUEL ONLY.DO NOT USE GRATE ManufaMmd y: F O IOR ELEVATE FIRE.BUILD WOOD FIRE DIRECTLY ON HEARTH.RISK OF SMOKE AND FLAME SPILLAGE,OPERATE ONLY WITH DOORS FULLY OPEN OR FULLY CLOSED.IF INSTALLED IN FIREPLACE PRODUCTS INTERNATIONAL LTD. Z Juty Aug Sept Oct NOV Dec A MOBILE HOME OPERATE ONLY WITH DOORS FULLY CLOSED-OPEN FEED DOOR TO FEED FIRE ONLY.WHEN OPERATED WITH DOORS OPEN THE MANUFACTURER SUPPLIED SCREEN 8988 VENTURE ST,DELTA,BC V4G iH4 ❑ ❑ El ❑ ❑ 11J MUSTBE USED.REPLACE GLASS ONLY WITH CERAMIC GLASS(5MM).INSPECT AND CLEAN CHIMNEY FREQUENTLY. UNDER CERTAIN CONDITIONS OF USE CREOSOTE BUILDUP MAY MADE IN CANADA 918-176c LOCCUR RAPIDLY.DO NOT OVERFIRE,IF INSERT GLOWS YOU ARE OVER*lRING. MA———A ———— C —————————————————— ———————————— r� 6G 7 n IV A O O Residential Property Record Card PARCEL ID:210/105.A�00 52 0000.0 MAP:105.A BLOCK:0025 LOT:0000.0 PARCEL ADDRESS:15`- 30 FSRE T STREET EXT. FY:2008 PARCEL INFORMATION Use-Code: 101 Sale.Pnce: 102;000 - Book: —02105 Road Type; uT.. Inspect Date: 69/2212003 Owner: Tax Class: T Sale Date: 12/29/85 Page_ 0191 Rd Condition: P Meas Date: BIGGIO,JOHN J Tot Fin Area 2584- Sale Type P Cert/bo6. Traffic: M Entrance" EIL-EEN'M�BIGGIO Tot Land Area: 3.25 Sale Valid. Y Water: Collect Id: RRC Address: _ Grantor: WILLIAM BiNGHAM" d `Sewer: Inspect Reas: fi5'STOTIEGL' 01921`AV ROAD(O Exempt-B/L% / Resid-B/L% 100/100 Comm-Comm-B/11/6Indust-B/L% / Open Sp-B/L% / CBOXFORD MA RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms': 7. . Main Fn Area: 1464 Attic: NBHD CODE 6 NBHD CLASS: 6 ZONE. R1 Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1120 Bsmt Area: 1080 Seg Type._ Code; �MetHod Sq PC—s 'Acre's Influ-YIN Value Class "" " ""'�" """ 1 P 101 S 43560 1.000 208,652 Roof: G .Full Baths." 2 Add Fn Area: � Fn`Bsmt Area:' Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0 2.250 17,100 Masonry Trim: Ext Bath Fix: 6 Tot Fin`Area: 2684-l' VALUATION INFORMATION Foundation: CN Bath Qual T RCNLD: 278121 Current Total: 503,900 Bldg: 278,100 Land: 225,800 MktLnd: 225,800 Kitch Qual: T Eff Yr Built:. 1987 Mkt'Adj:.� Prior Total: 537,800 Bldg: 288,900 Land: 248,900 MktLnd: 248,900 Heat Type: HW Ext Kitch: Year Built: 1986 Sound Value: Fuel Type: Gtt _ _ Grader _. Ad Cost Bldg: 278,100"" Fireplace: 1 Bsmt Gar Cap: Condition: AAtt Str Val1: Central At: N Bsmt -. Gar SF" OctPct Coplete. _. _ Att Str V612:" Att Gar SF: %Good P/F/E/R /100/100/90 Porch Tyne Porch Area Porch Grade Factor P 240 SKETCH PHOTO K` 12144 12 4n 12 24 2 M FRI 16624 S R 1180 SgM4 R 22 q' 24 4 µ r•" 1530 FOREST STREET EXT. 1 Parcel ID:210/105.A-0025-0000.0 as of 11/10/08 Page 1 of 1 t% TH oo" Andover T f 0 No. 32r3 0 LA 0dover, Mass, , 17).4 COCHICHEWICK 11. 7,95 ATED BOARD OF HEALTH Food/,Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...........4V.. 'elf di.o.............................................................................................. Foundation has permission to erect........................................ buildings on....zQlp..........C)..................5,1....................................... Rough ..V < .,�- ,7 e�,.�himney to be occupied as........................... ...... ... ..... provided that the person accepting this permit shall in every respect conform to theterms of the application on file in Final 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S TS Rough ".,r Service ..... ..................... .................... ....................................... ................... BUILDING IN9PECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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 Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det.