Loading...
HomeMy WebLinkAboutMiscellaneous - 8 EmersonDate .... .. 2 .. L . - . '06 .. . .. .... .. ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1,-,4 A /) '65-x C' 15 I-ef-C. r This certifies that ............................. ........................................ Gf Xr� has permission to perform .......... ............ wiring in the building of .... too.k.U.4. ...... 7w t- 5 ....................... at ..... ? .... 16-m-im—sp.4 .. ................................... . North Andover, Mass. .... ......... ...... ...... ... ... Fee.?,.(R.!►-- Lic. No. ............. jozl.�... ELECTRICAL NSPE AR ......... Check # -t\- Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.Vq W1 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 11/991 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: 03/08/2006 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) #8 Emerson Owner or Tenant Wood Ridge Homes Telephone No. 978-423-7867 Owner's Address 10 Wood Ridge Drive, North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No X (Check Appropriate Box) Purpose of Building Residence Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Removed medicine cabinet and installed new one Completion ofthefollowing table may be waived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool rnd. Above ❑ In- rnd. 1:1o. 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. InDetection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Key Sec ritNo of Devices or Equivalent No. of Water Heaters KW 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. 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 X BOND ❑ OTHER ❑ (Specify:) Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjuty, that the information o,# this acation is true and complete. FIRM NAME: Landers Electrical Co., Inc. LIC. NO.: A5912 Licensee: Terrence J. Landers, Vice -President SignatureZ LIC. NO.: 9743 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-686-3828 Address: 1000 Osgood Street North Andover, MA 01845 Alt. Tel. No.: 978-686-3829 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 a ent. Owner/Agent PERMIT FEE. $ 20.00 Signature Telephone No. (W4 I� \ N h U 00 O 0 ti tl � � W U � x Cd U O c N O °: o o "a ���•. rq Y e �M 3 00 A O 0 3 CA 3�°r� L O RE 9 O T O T O U .d 7 p 0 � � T � p C• C C C ~ aG � c°i30 3' u C °y tj o1 -i[-10,° °Eaiv3 3: yN >F.2r. ones �s �Qx G V to pp N O N -0.00Eo 0 w°cx�;!Or'- a d rr � 'UM) p E V «41 Q >i O .••n N (ti U Vl i U• OU N �U O O •C CO Op y N . b N in .y >,.c �,' vi C H •O 0 U O O N�'X C�YON b� C > C 3 'fl d L > a hw "2 O '0, •03°=�3 UbC a� v C > ami ob ti A ozz x � as N N C N a •C C y '� E bn 'O C F •,� op � 3 " •� a'Ci X� ^ 20 ti � •s b G y0„ ~ ° T�cYyE°v� c i0 O .d i O C 3 3 E 'Ob C>C o bs by �w 3 y t U E y .� U Y •� t�❑ .. O W A X pO�p� w v O O L y N 0.2 cd W CC y N O 0 0 C U d d `o > 3 �won� 0 onata o p O mvL'a2.1 81 Na�i�NO 0 Ec O � U � x Cd U O c N O °: o o "a ���•. rq Y .00 �M 3 00 A O � � T � p C• C C C ~ aG � c°i30 3' u C °y tj o1 -i[-10,° °Eaiv3 3: yN >F.2r. ones �s �Qx G V to pp N O N -0.00Eo 0 w°cx�;!Or'- a d rr � 'UM) p E V «41 Q >i O .••n N (ti U Vl i U• OU N �U O O •C CO Op y N . b N in .y >,.c �,' vi C H •O 0 U O O N�'X C�YON b� C > C 3 'fl d L > a hw "2 O '0, •03°=�3 UbC a� v C > ami ob ti A ozz x � as N N C N a •C C y '� E bn 'O C F •,� op � 3 " •� a'Ci X� ^ 20 ti � •s b G y0„ ~ ° T�cYyE°v� c i0 O .d i O C 3 3 E 'Ob C>C o bs by �w 3 y t U E y .� U Y •� t�❑ .. O W A X pO�p� w v O O L y N 0.2 cd W CC y N O 0 0 C U d d `o > 3 �won� 0 onata o p O mvL'a2.1 81 Na�i�NO n O czO O N O 10 u 4, •o N OA o- 3 N G ° •r U �> o" o y s aGy a 0 a y ay+ O CYO T _ .J""-� G U U U i n O O O 1 0 N O N A � C .� Q .� o £ u U Op U .a LC C C o �vCC a c 3 � t� RS u�•,c U 'p ed o a �°�o >� :o > XON :+' L O O .0= 'b z ti E 3 0 e y R� O '2 p 0 00 EJ- 0� o 0 ra o i N p x� •0 IE ° y >, v � u s F a'Y 0 00 � E 000 o n w rn N A Date. . z r • 0f.,pRTM,�'O TOWN OF NORTH *DOVER PERMIT FOR P. MBING s i r This certifies that ...!. t�'./�'�� f� ................ has permission to perform ..... ................... . plumbing in the buildings of ...-O.s ..... at ..... / 47/,/,. ........ North Andover, Mass. Fee . �31 <00 Lic. No... 5. 3 PLUMBING INSPECTOR Check # 7182 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location /-! * &4.9,1-51, Owner - Type of Occupancy / New Renovation 0 Replacement Plans FIXTURES Date Permit # Amount Yes 11 No (Print or type) Check one: Certificate Installing Company Name {'jiLO Corp, Address �- Partner. c SS © n Business Telephone Name of Licensed Plumber //l�/'%l (_�e/��_ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate bow Liability insurance policy Other type of indemnity 11 Bond ❑ insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner El Agent I hereby certify that all of the details and information I have submitted (or entered) ' bove application are tru accurate to the best of my knowledge and that all plumbing work and installations perfo ed a ermit Issued for is lication will be in compliance with all pertinent provisions of the Massachusetts State P i e apt 14 of a General Laws. By: signature oi LicensecrMumDer Type of Plumbing License Title City/Town License Number Master Journeyman n ` APPROVED (OFFICE USE ONLY {.� Date .1�16 �. . TOWN OF NORTH ANDOVER D OVER or PERMIT FOR 5P&BING This certifies that ... l' f. �l has permission to perform .f/vt_ • • •��tQ• °�•" plumbing in the�e buildings of .e.P ! � ... ,?� "P S• at ........t'��(?!t.S.n... • / ...... • .. , North Andover, Mass. Feef.30'. . Lic. No...� PLUMBING INSPECTOR Check # 7 181 It I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building �—Owners Name of Date I / Permit # Amount New 0 Renovation 0 Replacement 0 ----/Plans Submitted Yes E] No FIXTURES (Print ortype) Check oneCertificate InstallmigComp any Name�� 1:1 Corp Address v. � k C r cIEl Partner. S Business Telephone -P-7' 3 Co. r Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ©/ " ` Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application arehip and accurate to the best of my knowledge and that all plumbing work and installations performed and it Issued r 's plication will be in compliance with all pertinent provisions of the Massachusetts State Plu in a and Lhav a General Laws. BY igna ure o ns er Tof Pm glicense Title � (0 S City/ License Number Master Journeyman 1 APPROVED (OFFICE USE ONLY Date. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBII This certifies that5....9... ! f........ .... .. ..... . / C has permission to perform'' ....... . plumbing in the buildings of .414-1141 s........ at ... ...... .......... , North Andover, Mass. F�.•.Uv . Lic. No..r)6';)s-3 ....... PLUMBING INSPECTOR Check # �`1 � `� 7178 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location IF 6k.e -5,1 of Occupancy Date 1L--f-c-, Permit Amount New 0 Renovation 0 Replacement ®/ Plans Submitted Yes FIXTURES No 11 (Print or type) Check one: Certificate Installing Company Name El Corp. Address U�A_ C'I r'C-I 1-- 0 Partner. G6S d� Business Telephone 3:7,3 / Finn/Co. Name of Licensed Plumber. ( /-fe lktc-A S Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 9--- �- Other type of indemnity 11 Bond ❑ Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 I hereby certify that all of the details and information I have submitted (or entered) best of my knowledge and that all plumbing work and installations perform compliance with all pertinent provisions of the Massachusetts State Plu 4 By Signature ofTicensea PlumDer Type of Plumbing License Title G � -3 City/Town cense um er Master APPROVED (OFFICE USE ONLY Agent bove application are truand accurate to the ermit Issue=tee lication will be in nd'Chant�r General Laws. Journeyman rj --- Date f Of TOWN OF NORTH ANDOVER,- p PERMIT FOR PLUMBJNG 16 ,SSACMUS� '4 I This certifies that 1 :.'. s....,�. � .�� • • .. • • • • .......... • has permission to perform ... f 11.<. .'......,............. . plumbing in the buildings of atfLs ........ '................ . North Andover, Mass. Fee Lic. No.M.L?.}. .......... -�'-�....... PL�l1MBING INSPECTOR Check # 1 / 7150 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location A0,/'17 ners Name Gc/OGcI�✓ . 6F Date /0// 4 P -L0 -S Permit # 7 7 71)—o Amount 20 Type of Occupancy New E] Renovation ® Replacement Plans Submitted Yes No (Print or type) Check one: Certificate Installing Company NamexAL2J4�Corp. Address <fe ' a Partner. Ila 4- G,t&;S 01F-1-1 Business Telephone 3 42,` Name of Licensed Plumber: 4r4'11 Insurance Coverage: Indicate the type of ' mance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ■ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above .• Signature Owner ® Agent I hereby certify that all of the details and information I have submitted (or entered) in abov plication are true curate to the best of my knowledge and that all plumbing work and installations performed der i ssued for ' a i 'on will be in compliance with all pertinent provisions of the Massachusetts State Plu Co a 4 f eral Laws. By Signature oi Licenseau er Type of Plumbing License Title Mense City/Town Numoer Master ❑ Journeyman APPROVED (OFFICE USE ONLY 11' .......................ow (Print or type) Check one: Certificate Installing Company NamexAL2J4�Corp. Address <fe ' a Partner. Ila 4- G,t&;S 01F-1-1 Business Telephone 3 42,` Name of Licensed Plumber: 4r4'11 Insurance Coverage: Indicate the type of ' mance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ■ Bond ❑ Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ® Agent I hereby certify that all of the details and information I have submitted (or entered) in abov plication are true curate to the best of my knowledge and that all plumbing work and installations performed der i ssued for ' a i 'on will be in compliance with all pertinent provisions of the Massachusetts State Plu Co a 4 f eral Laws. By Signature oi Licenseau er Type of Plumbing License Title Mense City/Town Numoer Master ❑ Journeyman APPROVED (OFFICE USE ONLY Date.. TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 4L '7SA US This certifies that............... ...... \ i; . has permission to performMt . . ,t oft plumbing,i-'n the buildings ofh�, im'.1 /f at A ....... North ndover, Mass. Fee4� Lic. No:J/-30- PLUMBING INSPECTUR Check # Ill 6477 MASSACHUSETTS UNIFORM (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location ZCi TION FOR PERMIT TO DO PLUMBING Date 3 - O YS Permit # y 55 Amount New Renovation Ryacement 11 Plans Submitted Yes ff// FIXTURES No ❑ (Print or type) Check one: Certificate . Installing Company NameIY1160n o Corp. Address t`' Partner. usmess Telephone �Firm/Co. Name of Licensed Plumber: T 1 �, (A -J I LS CV, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0-�L Other type of indemnity 11 Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner I hereby certify that all of the details and information I have s best of my knowledge and that all plumbing work and installa compliance with all pertinent provisions of the Massachusetts VED (OFFICE USE ONLY Agent e9d) in above application are true and accurate to the der Pe t Issued this application will be in Code h e of the General Laws. T`y e of Plumbing License icense NumDer Master Journeyman 4!!� Location No.Date TOWN OF OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /,Cd on Check #�� r X6764 �---$Gilding Inspea�r The Commonwealth of Massachusetts State Board of Building Regulations and . TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code 780 CMR Zoning District Proposed APPLICATION TO CONSTRUCT REPAIR, RENOVATE CHANGE THEASE.OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number.. L Date Issued: ( AA,("'� Signature: Building Commissioner for ofBuildings Date SECTION 1- SITE INFORMATION 1.1 Angary Address:1.2 Assessors Map and Pinel Number. 7okvn) H4 Pawl Number Map Number J,3 1.3 Toning Idmudion: 1.4 Property Dimmeiocs: Zoning District Proposed Use Lot Are& (sq) Finatage(R) 1.6 Building Setbedc R a01/pL� Front Yard IJP Side Yard Rear Yard Required Provided Signature Telephone �� Required Provides Required Provided Company Name Registration Number I 0 %01 � 5' Address 3 WD 1 a.�d r ( -7 -r Expiration Date z • 107 Water & ffly 9M.O.LC.40.4 § 34i Public Private a I.3. Flood Zone Information: Zone n Outside Flood Zone O ow Disposal System: 1.8 Sewers Municipal 6 On Site Disposal System 2.1 Owner of Record Wo, Rt e l6rros C4�)o Name (Print) Address: lo wcPcAissr1 d e rz 4 ive/ Signature Telephone q 7 82 7Q4 3 2.2 Authorized Ag.�: I ' a M I'f F (31dr Name (Print �v Q Address 3 W o1 I l a ro k 4 jQ vid AA Signature p Tel one p (ow SECTION 3 CONSTRUCTION SERVICES FOR PRO. wrS I F44 THAN 1&000 CUBIC FEET OF RNCI.OSEU SPACE 3.1 Licensed Construction Supervisor: Not Applicable Q 7okvn) H4 Licensed Construction Supervisor: License Number O 33(3 Aadree Lv (1 l 1 Q vvl S �� a01/pL� Expiration Date 31 IJP 2� .2� Signature Telephone �� 3.2 Registered � Ho eat Cc actor* J 1 Not Applicable 13 Company Name Registration Number I 0 %01 � 5' Address 3 WD 1 a.�d r ( -7 -r Expiration Date z • 50 (.0 ?_3 Signature Telephone '? (:' & Revised 1997 JMC j 1" 0 0 SECTION 6 - DESCRIPTION OF PROPOSED WORK check allapplicable) New Construction 13 1 Existing Building Repairs U Alterations Addition Accessory Bldg. E3 1 Demolition Other C) Specify Brief Description of Proposed: fl g D tet- S T r✓t S 9— SECTION 7 - USE GROUP AND CONSTRUCTION TYPE Independent Structural Engineering Structural Peer Review Required Yes 13 No C) SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT USE GROUP Check asapplicable) Signature of Owner Date CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA 1B 0 Q B Business E3 2A 2B 2C O 0 13 E Educational C1 F Facto E3 F-1 F-2 H High Hazard C) 3A 3B C1 E3 I Institutional Cl I-1 I-2 I-3 M Mercantile 4 R Residential R-1 R 2 R-3 SA 5B Q Q S Storage 0 S-1 S-2 U utility Q S eci M mixed Use Specify: SS ecial Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existing (if applicable Proposed Number of Floors or stories include basement levels Floor Area per Floor Total Area Total Height ft SECTION 9 -STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes 13 No C) SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , As Owner of subject property hereby authorize T 7 P �� i Pr--, —in c . to act on my behalf, in all matters relative to work authorized 6y this building permit application. Signature of Owner Date revised bldg form/state JMC SECTION 10b - OWNER/AUTHORIZED AGENT DECLARATION I, , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Sienature of OwnerAzent Date SECTION 11- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building (a) Building Permit Fee Multi Tier 2. Electrical (b) Estimated Total Cost of Construction from 6 QJa' l� 3. Plumbing Building Permit Fee (a)x(b) 4. Mechanical WAQ 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number ' ✓ tii 'Poav�vnupa�G� �✓�gaaao%ioe!!d q QVIATIONS !I CONSTRUCTION SUPERVISOR NUMbjN033843 ISI 1955 Tr. no: 19350 - JOHN T HAFFE j 3WILLWuISR (�,,.,1,'e. WAYLAND, MA 01 Adminlatrator 8 l uo r. O b � O ^ o O O O FF O O i � CTJ U O Sa C,3U O M 0 O 0 4 0 0 N¢ O o u� o b MO 1�4W VJ W c 0 T 90 U� a� rn�r'- o > N L. Saco 0 0 LU LU co 5 ~ m o Q 0 a. C N 9 � �0 � :: U p _. N �... Q 2 t` O Q V a I E . Ln g y o W � w o a C4 v � o o m °m ~ o w " x o J o y W n n 0 s 5 m o m° LL 4 'DQ EiJQ� = I m Drlt) �03� 0 , t•; x ' The CommonW6041. dfi a usetts Department of ItidU;,�ents Office 0.: nV 8 l aZfgns 600 Washingi~o' Street Boston, Muss: 021.11 Workers' Compensation Insurance Affidavit City: N o r't'e (} nctb Ve r rnq phone # ❑ I am a homeowner performing all work myself, Oftictai use only ❑ I am sole proprietor and. have no one working in any capacity I am, an employer providing workers' compensation for my employees working on this job. Company name: IT . . l o,-P�eq B U + l U-5 ml c_.. ❑ t3uilding Department Address: ' 3 Ti u ias r d , tmltlUcens@ City:a-v> t'11i1 ® t `i "Z 8' c phone # SO S Co 2p `t l �0 8 Insurance co. oiht� +•crqV—Q policy # WG192 �i r ❑ I am sole proprietor, general contractor, or homeowner, (clrclO one) and have hired the contractors listed below who have: the following workers' compensation policies: Health De'pahment Company name: ,YY . ' : a-,. „ , ;' rte:.: w .• . Address: • y�_ t � •''.i,'.1 City: phone # Insurance co. policy # Company name: ,�1 • Address: t r: City: ;� phMe # Insurance co. " -,. �,., ., policy # Failure fo recur@ coverag0'as f ql ti U11 01'. of.�tOL°1 'aa�`��p�;to;thj;Opp I�Jon of criminal p@naltie='of a fine up to $1500.00 and/or one year': impr(sonment a: Well as cjyU penaitls# In the form of a $TOP WORK ORDER;and a fik# $100,00 p day against me. I understand that at copy or this statement may be forward@d to the Office of Investigations of the MAI coverage verlticatlon. /do hereby oertlfy under the pains and penalties of perjury that the information pro'...dabove is true and correct. Signatur@ Date Print name pfi0pe 0 '•i : r J� �� {f Oftictai use only d of wd.(0ri this area to be compl8ted`b 'bJ�y o i V�i1 official . rTV:vr��ljt;.. ` + fR` "'y `1 ❑ t3uilding Department C or.town: , tmltlUcens@ •!h!•...: ,. r' .. a . t t,WYf �r% riul: ,. []• Licensing Board r Q $electmena Office: QChBCk K Immediate r@apOni@ IS rBQUlred : :' ' Health De'pahment cbotact person •�liJ,�,:' ,YY . ' : a-,. „ , ;' rte:.: w .• . D Other • y�_ t � •''.i,'.1 �y.;�,. x S ; � °C. �+ •� f �.j:'R}' d�� �k Kaki «!� jt, t {hr >+ul ii±�'' :: jj•� s J 7�{ U�. Ii.K..t•.V1dl iwW+ y t. "t W4 ,41.»tk: ��St'..n' i1�:.1: Y, n. tii:u, .1—4.. iw 9...: •)i..a 1' .. .. ,�1 �i71NY�rY{34]1 VL ;. �tJ:t';�.t •tijr./!'r� { �tt G'i "' t r: North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this 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 in: _IQ uy)-�Q n M at s sIC- �� t000 sa (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT [M.G.L. a 152 § 2586)1 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 No SECTION S - PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 3 000 C.F.OF ENCLOSED SPA 5.1 Registered Architect: No Applicable Name (Registrant): Address Registration Number Signature Telephone Expiration Date 5.2 Registered professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 53 Gmend Contractor Not Applicable 93 Company Name: Responsible in Charge of Construction Address Signature Telephone M M M Cl)V 0 CO) CD � Z CD O ar d d a� � o av CCD CLQ CD O CO) CD 0 O COD C�. 0 CO) CDO CD CD a, H CD CO) �71— �O Ot = O ..y O cr N So5m -o y 3 amC, o C) HC2d0 M ID Z =r -C y 0 all. o .o CL m O 0aN O CA NCDZ O m O d n0 O co l'! .A moo. aE c CDy 3 CIOm m c» ±. lJ gQ *e . o d Cn y �<z•m .rt N c/)y Xv,CA 0 O O C=D m =yto 0 IF O = o n o. q D cp 3 o coj� , 0.r O M 7 o ��� p o x 0 PC 0 x p n� ar o o d �$ b C/)p CA g r Q 0 c