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HomeMy WebLinkAboutMiscellaneous - Exception (71)-��"�a��:x-i4��N v"p i 'z�, pbgg(q!-g-',11' ,.r r a '• .,ry K 'l, h ;�ti �„f � i� KF'k� A.T �. corn'n-u'.uuty t"e Yaa .27 es - N . xfl."n fg2:3sc.i.k,."y 'ts$ssa:i'b€ ,yak.ia D, Ri-iberf. December 5, 2004 To Whom It May Concern: tis^J _, 6SP9`5 4 1 Please be advised that upon review of the folder for 190 Dale Street, North Andover, MA it has been discovered that there are only 3 permits for the project. One is a building permit for the enclosure of the carport and for the construction of of living space. on the second floor. One is an electrical permit for the project issued to a R. Legrice. One is plumbing permit for the project issued to Tim Coyle. I hope that this letter satisfies your needs. Respectfully, Michael McGuire Local Building Inspector Location CID. ba I S No. g Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # �=q a l L- a 46 (Ca -, 16 3 6 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING T iB %r iC t i38C 0,11 BUILDING PERMIT NUMBER: DATE ISSUED: /c;2_ a ` U " SIGNATURE: ✓ Building Commissioner/1for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Address: 1.2 Assessors Map and Parcel Number: QjProperty I D 'Dales Si L 3u Map Number Parcel Number 1.3 Zoning Infomnation: 1.4 Property Dimensions: 3 2 S' X l30' R 3 41,0,060 1 Zoning District Proposed Use Lot Area Fronta e ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide R "red Provided Required Provided 1.7 Water Supply M.G.L.C.40. ti 54) Zone 1.5. Flood Zone Information: Outside Flood Zone 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System Public ❑ Private ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record A s , Name (Print) tj Address for Service ? 4.'9!1-604.9 Signature Telephone 2.2 Owner of Record: a Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ abe� J t Agtr Licensed Construction Supervis r: 0-7 222 (a License Number Address / L W �e & 2��+�'�.s4. 010? Y t6 o-) ) q2 4 " q 9 O Z. Z QO S Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ 'company Name Registration Number 11 lAddress Expiration Date Si nature Telephone It SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) 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 ...... c9_ No ....... ❑ SECTION 5 Description of Proposed Work check all gppllicable New Construction ❑ 1 Existing Building K I Repair(s) ❑ 1 Alterations(s) tWL I Addition ❑ Accessory Bldg. ❑ I Demolition >l I Other ❑ Specify Brief Description of Proposed Work: N(_ 63tdq Px4s; 1NS CAlzD'Irl r,tid PtYy 2.^�d- _I60fi-�� �x lsT� !vG- i'*64SL E9 x40 I) Mer'10 *11113 El 101 1X914=1 I ROO IjUSUECIM &�l Item Estimated Cost (Dollar) to be Completed by perrmt applicant OFFICIA VSE'ON Y 1. Building 640 (a) Building Permit Fee Multiplier 2 Electrical LAW (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) -� 4 Mechanical HVAC Q 5 Fire Protection 6 Total 1+2+3+4+5 0 , oa Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, V E as Owner/Authorized Agent of subject property Hereby authorize' R O 8ca T fZ to act on My behalf, in allmatters elative to wo authorized by this building permit application. -.� 1116 —Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, V'1 y) as r/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge andtt belief Print N Si ature of Owne4gentl Date NO. OF STORIES SIZE BASEMENT OR SLAB KD SIZE OF FLOOR TINMERS 1 2 3 SPAN DDv ENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS —1 IE, IG FIT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Add - FORM U - LOT RELEASE FORM aN� INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT_ (,, ,.. ✓--�-U' PHONE—J�03 LOCATION: Assessor's Map Number PARCEL_ SUBDIVISION LOT (S) AF Gt'14P ;9� 637 STREET I O ��L� ST. NUMBER_ "`OFFICIAL USE ONLY REC MENDATIONS O T WN AGENTS: � f CO SERVATION ADMINIS ATOR DATE APPROVED - DATE REJECTED COMMENTS �:�`�`Iru►4,1 /OOPo.�, Dl'OD�S�d sti TOWN PLANNER COMME FO INSPECTR-HEALTH SEPTIC INSPECTOR -HEALTH COMMENT DATE APPROVED . DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE- REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 im TE 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 properly licensed solid waste disposal facility as defined by MGL Chapter 111, S 150 A. The debris will be disposed of in: O \4*4ruO "S:> ii i-- pST� error- "` ��,�^�S�ici I z nar `17 Z,k;, 34a- R.G (Location of Facility) - (60) ((72 - 6333 Signature of Permit Applicant �! 03 Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector Cl v �'-n w �;um v tb =may 7 a An u► c a ?s n o !a*-� z0 o co cN`o n., o -4 or, cn o HO N Q 2 w zim .c�� 3 -CM �. m c l c �r i (p l \\�0 CD / � \�§! 302, $/ 0a \\| $ 17 o 2 r -° #�Q 2 � I ;r # | . CL Gn v c��Tx m�m�cncn O m m mmmv. ow,x0o,< y m vn�D r o v tom T D CD O 2 = m ' p T C- mCD 0� s 0 m O o 3 m OD O V < m m -TlO W Z z N c D O N) N D N A y n N T N T Ow m7wm2�10�� z o O 3 cn Vn X -. 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Z v�o o„ CL O N Cn aaZ M 5 D G) N oz N A aO 00 Z G N A CO m A mm� w n 0 n a a 0) N N X N A A n N N N O O CL O C O O m m 0 y m CD (D r o v o ' p T C- y 0 m O o G) r m � O V < m m -TlO W m c D O g D N A O z o c D CD w X N V O O (C W 3 T0C� T w o o Dw m D .... c CD � w � � r �o p �o N O % 0 0 0 O fDD) N D) N (D N j (D M fD CD y 0 0 <�0-0 CDa Qm�fo r c; v OCD O 'CD Cil o oo O m O 00 o X o a o Z OTM ft 3 m �m W 0 , x 0 o m r D 0 `) m A Cf.) CL CD `L N ad mEA O m f�n -• o m r m Gn D O C O N (D N cn aO'v` o CD (D Wy CD o ' cn;ox;; y CO N N p N N m 00 :� O O 0 0 w /i FORM U - LOT RELEASE FORM a N J (dor INSTRUCTIONS: This form is used to verify that all necessary approvals/permits Boards and Departments having jurisdiction have been obtained. This does not re, the applicant and/or landowner from compliance with any applicable or requirement *APPLICANT FILLS OUT THIS APPLICANT— LOCATION: Assessor's Map Number SUBDIVISION STREET_ PHONE �03 ir, p cj.3., PARCEL-5— LOT ARCELLOT (SJ ST.NUMBER_ --- --- —"UFFICIAL USE ONLY J MCI'. M11-NUAHEONS O T WN AGENTS: 4 � f CO SERVATION ADMINIS ATOR DATE APPROVED 0 DATE REJECTED COMMENTS �,© s 00 �/'o TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED - DATE REJECTED SEPTIC INSPECTOR -HEAL DATE APPROVED DATE -REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT- - FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR _DATE Revised 9197)'M <o 143NI I z= J,9H3 OO_ : H'_d3S ppr, - - /\ Z9 1:i id RAS " Jp azt Sgt / .Sgz 69 g- - Z6,0 OtI06-0 LZ Zb 59 -0t ICE _ zz bib, �c ptb - SI 6 i 91 tr1 Lt I x3 OL-9L£ oti g� jvzz - 9 61 i- 9L£ 3voZ IL- gL£ sjgF_[n RVld AAs U 4 t ov ICz 9 ZL- flL£ L N L- gL£ N n `' tom/ Sim 000`ov awa ov ccz tn _ cti 5L- gL£' J 93A1 ov Ib z O'er bZ T Z eam . ov IbZ Z- gL£ b9 -om IvIld EIRS N 10'3 r 00 � C(o -D PA --e- S --F r s 1, -ado -------------- 20'8 48'2 27'3 __J existingl st.floor 6'2 p 7 I� 3'2 6'6 774 3'6"4 17'4 48'2 10'8 �67 5'45'4� J� UU1l e0 00 'B CLQ 200 00 Oo 90 to � N r M 9'11 5'2 5'3 — 5'5 2'9 —1015— 36' 24'5 4'4 T3 -----------------------------•----------------------------------------- HALL ------------ -LdHALL I 14'6 x 3'9 C3I I I ' I MASTER BATH LAUNDRY 133x8467x84 ' 0nCLOS.Er6'7 I I I I I I I I ' I I I ' I ' 1 BEDROOM . CLOSET 1 I ' 11'3 x 18'11 6'6 x 10'6 I ' 1 ' I ' MASTER BDRM 16'7 x 14'5 ' I ' I ' i 11'3 I \ ' I \ ' I \ ' I \ ' I I 11'11�I '�----------------" 241 11'11 I 24'1 - 36' h 48'1 21'9 28'4 — 9'1 I , I I existing uPLill' uP I Ll1 I I I I � I I xtw U I I < i S r rL Al t v 1019 N N I d }�j I r I I 1 I ID— i i ti . 3'2-� ss"ir i i V - -----------y �-------------y I I � I t---------- ------------- 481 �R General Contractor 75 Frost Road DERRY, NEW HAMPSHIRE 03038 (603) 434-4902 Fax (603) 434-9174 TO: George And Judy Dyer 190 Dale Street North Andover,MA. 01845 PROPOSAL „e, CUSTOM HOMES • REMODELING & ADDITIONS KITCHENS & BATHROOMS • DECKS & PORCHES PHONE DATE (978)689-0069 10/21/2003 JOB NAME / LOCATION Garage and Remodeling JOB NUMBER JOB PHONE Remove existing carport,fireplace and roof.Build a new 2nd.floor and one car garage as per plan.This price includes the flowing all site work,concrete footings,concrete frost walls,concrete slab,all framing,roofing,pluming,electrical,insulation,drywall,painting,vin, siding,intexior.trim with six panel hardboard doors,heat and central A/C. This price includes a $14,000.00 Allowance for kitchen cabinets,tub for master bath,light fixtures,garage overhead door,front door,any new windows,fireplace and stair parts. This price dose not include removal of ledge,unsuitable materials,shoring,dewatering or flooring. Contractor will remove all demo and scrap materials from job site. All work comes with a full one year guarantee All state and local codes apply We Propose hereby to furnish material and labor - complete in accordance with the above specifications, for the sum of: One Hundred Fifty Four Thousand Six Hundred and 00/100 Dollars dollars ($ 154,600.01 Payment to be made as follows: Acceptance of Proposal - The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do - the work as specified. Payment will be made as outlined above. Date of Acceptance:Wo vEm a �C--2 6 i ® 3 Signature L Signature Note: This proposal may be withdrawn by us if not accepted within-� ' days, and is subject to the terms and V conditions printed on the reverse of this p- e. Authorized Signature �Vj I CONSTRUCTION CO. TERMS AND CONDITIONS It is mutually agreed between the Purchaser and Agri Construction Co., hereinafter called ACC that: 1. The title to and right to possession of all materials delivered, whether stored, erected, or in the course of erection shall remain in ACC until the same shall have been fully paid for.. Should the Purchaser make an assignment for the benefit of creditors or become insolvent, or there be a Receiver appointed for his property, or shall he fail to comply with any of the terms of this proposal, the whole purchase price, including all notes, drafts, or other obligations given on account shall, at the election of ACC, become due and payable forthwith. If any claim which ACC has or may have against the Purchaser under this contract is referred by ACC to its attomey for collection or enforcement, the Purchaser shall be obligated to pay ACC an additional sum covering attorney's and/or collection fees. 2. No creditor allowance shall be made to the Purchaser by reason of any changes or alterations either in the specifications or the work, unless the charges or alterations and the creditor allowance are consented to in writing by ACC. No charge shall be made to ACC by the. Purchaser for work performed or materials or equipment supplied by or through the Purchaser unless such work, materials or equipment, and the cost thereof, is previously authorized in writing by the General Superintendent or an Officer of ACC. 3. The Purchaser shall notify ACC in advance when the premises will be ready for the installation of the materials; shall, at all times, give free and unobstructed access to the place where the work is to be done, and shall put up and keep all surfaces to which the material is to be applied in proper condition so that the work can be started promptly and, after it is begun, can be prosecuted continuously and completed without delay. Should there be any interruptions to the work by any cause not attributed to ACC, ACC shall be paid by the Purchaser in addition to the contract price, all expenses that.it may have incurred on account of such interruptions. ACC shall not be required to deal with anyone on the job except the Job Superintendent. It is mutually agreed that ACC is best informed as to when men are needed to perform and complete its work under this contract ins promt and reasonably diligent mannerand its decision shall be final as to Me sufficiency and type of men it shall hire and pay, such men shall work for and take orders only from ACC, and the Job Superintendent shall deal through ACC's work superintendent. 4. This contract shall not be subject to cancellation by the Purchaser after ACC has approved this contract, without payment of proper damage to ACC. 5. The Purchaser shall, without charge to ACC, (a) supply sufficient locked storage room undercover for all materials furnished; (b) allow the use of elevator or such other facilities as maybe available for the handling of materials; and (c) furnish all water; heat and artificial light required. 6. The Purchaser assumes all liability for damages to, or destruction or loss of any goods, supplies, etc., by fire or otherwise after they shall have been delivered at or on the site of work. 7. ACC shall not be held accountable for damages or delays, due to war, strikes, fires, accidents or labor difficulties; or for any contingencies that are unavoidable or beyond the control of ACC. 8. There are no promises, agreements or understandings not expressed in this proposal. 9. ACC shall not be liable forany safes or use taxes for the work or materials covered by this contract. If any sales or use taxes should be imposed, the total amount thereof shall be added to the contract price and such amount shall be paid by the Purchaser with the final payment due under this contract. 10. This proposal shall not constitute a contract until approved in writing by a duly authorized officer of ACC in the space provided for such approval on the reverse side of this page. 11. On projects over$1,000 progess payments consisting of 95% of the value.of all materials furnished and all work performed during the month is to be paid us on or before the 10th of the following month. ACC reserves the right to remove all men from the job if customer fails to make progress payments on schedule. Balance in full upon completion. 12. On projects under $1,000 payment in full upon completion. 13. A finance charge of 11h% per month will be charged on all overdue accounts. 14. Any alteration or deviation from this shall be considered as an addition to original contract price. 15. ACC will not accept any backcharges unless approved by company officers. AGRI CONSTRUCTION 75 Frost Rd. DERRY, NEW HAMPSHIRE 03038 (603) 434-4902 JOB '-D 4 L:E (L I qO 'D Ate- J7� SHEET NO. I OF 2— CALCULATED BY ��� DATE 11I�I6 �9 CHECKED BY—// ,/// tt DATE LL � s'6 7 SCALE l'/` I" _-1- rOJT PRODUCT 204-1 (Single Sheets) 205-1(Padded) ®e Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1 225-6380 AGRI CONSTRUCTION 75 Frost Rd. DERRY, NEW HAMPSHIRE 03038 (603) 434-4902 JOB �1 (�Gr Y`e/L 1196 SAA SHEET NO. OF CALCULATED BYd�- DATE l ✓/-� CHECKED BY DATE PRODUCT 2044 (Single Sheets) 205-1(Ped led) ®® Inc, Groton, plass. 01471. To Order PHONE TOLL FREE 1 ADo-225-6380 C rF CO2 CD n Z CD O CL r CL i 'D � O O CL ca CD o C CCD CL C2 CC2 CD C031 CD a 0 O CO2 n� c 0 c CO) d n CD 0 CD to CD O CD 0 CCD G C �� p --i O -�viOQH O.a � O y »m O ® O N CCA C7 CZ C-) "� m Z =r= N O� .► = -* CD CO) TI =F CD n � M = y CD -40 m N p O � CD O Z =CDobC3 Oto a = ...� O O N C9 • CD .� R CL nam '• CL um 0 �?Z DCD n c ca ♦ i ma. O a C%l IN N l"f Z N Q. CS _ C ►n cn a J a V N CDcn :^ m f0 • C �, N `� `a Xle CD 0 3 Wim: zo �@opo . cn w OCD CD c CD ��. CD N Oq CTS � CD " =3 CL atp O : CD y 0 9 z d � nCD � O to � � � O 'z7 O 90. 0 C7 Cn t� n � `S7 O rD Q C v M M I S„ 'roPsotl, F Su sol G rzgvEL �Z' GeA sq,9AAj .Sq ity qo„ o 9A U 108 06 "JATE(?e-iog" EST, S,H•W,T(E 78" I ,o m n 51 `M-27 dog jr)ucTF—D 1 o -q-q Z By Fl.E,S, ruc. < ul'T-AJF9XEp 13Y -W�y ST -A 2V—, H �A1,T - A6E,,T, �l�llFSh'ttTH Z�, /Ig J-07— q 0, Ooa S, F` • 37-t3 PA1-'.5) eoP,(.EACr�(r�rCT 'TI7�'LrCftES cs' w % br— ! Z'' DET - P Bete,) 11,10 _ 5b VxiST. I HSE 190 130 ' D�-. A PPe6x , toe-A7i oL( of Ext ST. SEPTI G TALC r- — To 6�c- 1ZEP-4 cru W T -H , lCO 1500 GAC.. (fo)x, SEPTI L T1}u(G Nor,Es : /. ALL --II-Z- TO %5 CGEAA/ JXWO OR a,% !kWL ~k-Wa A PERCoLAT/ON RATE of Lis 77,1,9.v OW 6�Va44 701 2,;W/1u./-vcy ,gFTER BE/NG PLACED 4A49 Pi94r�EiYLY CDrt1,oACTEo 2. ALL STJJ�f/E TO BE l4/.4SHE0 AS NECES,SARy 71> REtifOI�EF/NF3 Ousr. c3. T.'/.CS' SY,STE/i! /3 if/OT OES/6if/EO F`�i9 T.G�E'GFSEOF,� 6vORB4GE 4. 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Go GA-11ou off' FXtsrluCr L1cACNtuCh F`ACi��'rY -iSIZE � ( �'YPE Vu06TE2F1lt,.rEpj , SEPTI Cr 7"A�IG G_jTcF R-AIll FoR R PAIR Z O�- SuBsUPFAcE DISPOSAL SYsT BAY BAUK /Z-/ MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 0 TEL. (508) 475-3555, 373-5721 • FAX (508) 475-1448 � '7 - ,- 41 Date.....................'/ ...... / .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4biscertifies that............................................................... I ............................. has permission to perform . ................................................ wiring in the building of .......... . e .................................................................. at ... . ,North ..... ............. ...........................................................orth Andover, Mass. L--- — / ' /�� I - ("4 " FeeZ�� ......... Lic. No. ....... I ........ A . .................................... ELECTRICALINSPECTOR Check # 5,%142 Official Use ,Onnly Permit No, Z- D� a� prt6lte Satiety Occupancy &Fee Checked BOARD OF FIRE PREVENTION REGULATI, NS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance wit the 1�4ssachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspector of :fires: Town of North Andover The undersigned applies for a permit to perform the electrical work described Location (Street & Number. Owner or Owner's Address i fi / L Is this permit in conjunction with a building permit Yes OL/' No 0 (Check Appropriate Box) Purpose of Building ! I- r S_ Utility Authorization .:�L C) 3 ys' Existing Service /G `' Amps Voits Overhead 9--�'f Undgmd 0 No. of Meters 1 New Service v Amps Voits Overhead L,1' Undgmd 0 No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO - have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: ft FIRM NAME 41,4 6 A -Al LIC. NO. NO. C /�-_ 2 C f Bus. Tel No. G, FY Z J"� C Address C S a Ni q / t ST %� ✓� L L f Aft Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE Total No. of Lighting Outlets No. of Hot fuse No. of Transformers KVA r Above 0 In 0 No: of Lighting Fixtures Swimming Pool gmd 0 gmd 0 Generators KVA No. of Emergency Lighting N1. of Receptacles Outlets U No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ran es I No of Air Cond Tons Initiating Devices Heat Total Total No. of Diposal No. Pumps Tons KW No. of Sounding Devices NoJ of Self Contained No. of Dishwashers f Space/Area Heating KW Detection/Sounding Devices 0 Municipal 0 Other j No. of Dryers Heating Devices KW Local Connection P No. of No. of Low Voltage No. of Water Heaters KW Signs Bailases Wiring . No. Hydro Massage Tuds No. of Motors Total HP OTHER: INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO - have submitted valid proof of same to the Office YES = NO - If you have checked YES please indicate the type of coverage by checking the appropriate box. INSURANCE = BOND - OTHER - (Please Specify) (Expiration Date) Estimated Value of. Electrical Work$ Work to Start Inspection Date Resquested Rough Final Signed under the Penalties of perjury: ft FIRM NAME 41,4 6 A -Al LIC. NO. NO. C /�-_ 2 C f Bus. Tel No. G, FY Z J"� C Address C S a Ni q / t ST %� ✓� L L f Aft Tel. No. OWNER'S INSURANCE WAIVER: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE Name: Location: City Phone 71 am a homeowner performing all work myself. F�I am a 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: Address City Phone #: Insurance Co. Policy # t Company name: Address City Phone #: Insurance Co. Policy # 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 r� understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the pains and penalties of penury that the information provided above is true and correct. Signature Date Print name Phone # Official use only do not write in this area to be completed by city or town official' ❑ Building Dept F1 Check if immediate response is required Building Dept ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #. ❑ Health Department ❑ Other FORM WORKMAN'S COMPENSATION Date..��! 3 t Yr NpRTM pe<<`•O -.'tip TOWN OF NORTH ANDOVER 3j .! °c PERMIT FOR PLUMBING 41 ,SSACMUS� a This certifies that a has permission to perform . ................. . plumbing in the buildings of .. e . .. ............. at./. �........:�: ... 4. .............. . North Andover, Mass. Fe '??,� . Lic. No.�.�. �� . ' .rte.' ............ . � PLUM IN61NSPECTOR Check # Jo�J t MASSACHUSETTS UNIFO (Type or print) NORTH ANDOVER, MASSACHUSETTS Building APPLICATION FOR PERMIT TO DO PLUMBIN New M uio4'A to n t G k Type of Occupancy's111o, I tnni l, U Renovation r" Replacement FIXTURES Date — l `& 40 Permit Amount r Plans Submitt esNo ❑ (Print or type) n Check one: Certificate Installing Company Name J. /J / D Corp. Address /(t✓10 n AW Partner. Business a ep one ElFrm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of ' surance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond F1 Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above threeinsurance Signature Owner F1 Agent 11 I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations erfo ed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa etts St e P in ode and Chapter 142 of the General Laws. By: Ig e o icense r Type of Plumbing License Title 12 Z41/ City/Town License lNumuer Master Journeyman ❑ APPROVED (OFFICE USE ONLY