HomeMy WebLinkAboutMiscellaneous - Essex St 57G
Location
b.
No. C
Date rl
N0^TM
TOWN OR NORTH ANDOVER
cp
'
Certificate of Occupancy
$
Building/Frame Permit Fee
$
••°''<�
s,4S
Foundation Permit Fee
$ --
Other Permit Fee
$
Sewer Connection Fee
$
Water Connection Fee
$
TOTAL1,0
$ r>
')�, 6 t/
Building Inspector
1050/39 11:28
58.00 PAIR
Div. Public Works
�K--=
X
w
C. Ca
Q
�
W
y
y
Y
N
o
d
cn
Q
pr
-K
z
Q
F
t
O
.~
Q
w
w
�K--=
X
I
N
F
�
W
y
y
pr
-K
L-C-C
t
O
z
w
w
w
zz
V
O
H
m
x
m
a
m
v>F.
K
z
w
O
Q
O
O
Q
d
z
0
a0
U
U
M�M
L
tsar
ti
`�
ti
w
wq
lw-
Fw-
aU
F
A
O
C
a
4
D
z
U
z
U
z
U O
z p
m
m
m
U
a
U
O
F�
z
o
0
0
o
z
U
z
0
0
0 e
a
O
F
w
O
U
U
U -j
w
w
w
to
I
N
F
�
W
y
y
pr
L-C-C
t
O
z
w
w
w
zz
V
O
H
m
AGq
m
a
m
v>F.
O
z
0
H
4
F�
z
1
w
F
z
w
z
0
°z
a
C
O
E
M
Oi
m
a
a
a
e
Z
>'
F
<
�l1
w
M
m
t-
?
z
O
!
w
N
w
a
Fp
z
[
O
Z
O
<
a
a
W
Zw
e
h
G
w
OU
d
"'
to c
w
a
q
Z
L
a
z
p
p
z
a
e
w
d
z
O
Fe
w
m
z
z
z
O
Q
.=
-j
m
q
O
F
LG
z
w
7w
y
W
qm
m
m
Go
a
i"n
C
q
q<
ti
5
m
z
c
a
0
I
F
�
V
U
I
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name _ _ Please Print
Q
r---
—�
0 1 am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
0 I am an employer providing workers' compensation for my employees working on this job.
Company name: -
Address
City Phone #:
Address
City Phone #:
Insurance Co Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00
and/or one years' imprisonment as well as civil penalties in the form .of a STOP WORK ORDER and a fine of ($100.00) 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.
l do hereby certify under the pains and
Sig
Print name d V
that the information provided above is true and correct.
r
Official use only do not write in this area to be completed by city or town official'
6'- I-
ie # -"16C?.— qc �
City or Town Permit/Licensing
Building Dept
[]Check if immediate response is required ❑ Licensing Board
❑ Selectman's Office
Contact person: Phone #. ❑ Health Department
❑ Other
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 Permil
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:
51r,
(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
v
0
b
�¢
�
�
w°
L
cn
24
O
CG
IS
-o
��+3
r.°
.c
w
U
_
mco�
w
w
O
a
x
°
w
W
O
w
U
U
w
w
W
to
P°
cn
w
O
C�
c4
w
w
Q
w
,.
v
w'
d
2
cn
v
Q
o
cn
• c�
o
CO_ c
c v
o �
C H
O C
� O
' V V
R R
CD C
t
O R
CD
IL
.
Q
♦:ts
vy o a
•+ N
V:
• c
o
u c
m c
` N R
3 L
N m
m N
*: tee:N W C
0 . _
m
m o �
c�
o.v m
N m ;
C C m
m O �
v LZ o
R O � C!
v CL c
Q m ®c c
x m :mho N
:a
N m 0 ~ m
z
c R t mui
..
'y .Q=R. R c z
�caE ca m .N O
V O m C
COD a m '� O
x `+y':9
F- r sam
CD
0
E
CD
0
t Z
0
y
v CD
H
Q •O
L
o a.
CD
O
co
C.)
CL
N)
O
O_
ci
•iZ.
CO)
C
olO
R
.0
cc
d
CAO
L
O
V
CD
CL
CO)
C
C7 p�
c
o •�
o :2
CD
m m
Lft O
L
O
0..
cma
c
O O
O CO
Z CD
CO)
C
uj
_0
U)
CO
cr
W
W
w
U)