HomeMy WebLinkAboutBuilding Permit #651-14 - 105 HIGH STREET 3/24/2014 i
I
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit N0: Date Received
Date Issued:
I WIPORTANT: A licant must complete all items on this page
LOCATION
Print.
PROPERTY OWNER L S ek ,n, ev- r•'
Print 100 Year Old Structure e n
MAP NO: PARCEL: ZONING DISTRICT: . . Historic District y no
Machine Shop Village yes no
TYPE OF IMPROVEMENT. PROPOSED USE
Residential Non- Residential
❑ New Building One family
❑Addition ❑Two or more family ❑ Industrial
11 Alteration No. of units: [ICommercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition Other _�s��•.��^
Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
7�6 x -se
cellae r
A dd Q 3 rpo_Po,,,,- 4 lo-,) t VrK Y6 eetli-uf
Identification Please Type or Print Clearly)
OWNER: Name: 1-1,5c /�✓��•K Ke G� r Phone:
Address:
CONTRACTOR Name:..., << �� Uv�c S Phone:
Address: p , C / •l w f9 ek`�la o
Supervisor's Construction License: �Q l�sExp. Date:
Home Improvement License: 14e(179 -3 Exp. Date:—//1 �0/
ARCHITECT/ENGINEER �``� Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASEDAA��ONN$125.00 PER S.F.
Total Project Cost: $ � o2S 9 FEE: $ SPG ,VV
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the g araIty
gnature`_of Agent/Qwner Signature of contractor
Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
J
- Plans-Subrrmitted ❑ '..Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
:WYPE-OF-"SEWERAGEDISPDSAL- m
Public Sewer ❑ Tanning/Massage/Body Art ❑... Swimming Pools i ❑ ;
Well ❑ Tobacco.Sales ❑ Food Packaging/Sales ❑ ~ `
Private:{septic tank,etc._ ❑ Permanent D mpster 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
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Wates' & Sewer ConnectionlSignature& Date Driveway Permit
DPW Tow;: Engineer: Signature:
_r Located 384 Os ood,Street, .
FIRE D E 0.A RT M E N't Ter on site yes no
Located at124Mair Street
Fire De`partme►itsignature/date ' r ` °* ',...,;,,, ,,` .- ,•3 { { _ - :^
COMMENTS �. �
Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions.
.Total land area; sq. ft.:
ELECTRICAL: Movement of Meter location, roast or service drop requires approval of
Electrical Inspector Yes No
DANGER ZONE LITERATURE: Yes No
WL.Chapter166.Section 21A-F and G min.$100=$1000.fine
NOTES and DATA— For department use
LI Notified for pickup - Date
Doc.Building Permit Revised 2010
Building Department
The foiowing is"a list of the required.forms to be=filled out-for the appropriate:permit to.be obtained.
Roofipg, Siding, Interior Rehabilitation Permits
c ;. Biailding Permit Application
o Workers Comp Affidavit
o Photo Copy Of H.I.C. And/0'r C.S.L. Licenses
o Copy of Contract
'
o Floor Plan Or Proposed Interior Work
o Engineering Affidavits for Engineered products
NOTE: All dumpster.permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
o Building Permit Application
o Certified Surveyed Plot Plan
o Workers Comp Affidavit
Li Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass check Energy Compliance Report (if Applicable) t
o 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)
L3 Building Permit Application
o Certified Proposed Plot Plan
o Photo of H.I.C. And C.S.L. Licenses
o Workers Comp Affidavit
o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Copy of Contract
o Mass check Energy Compliance Report
o Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cans if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the apt)•?al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submAted with the building application
Doc: Doc.Building Permit Revised 2012 .
Location
No.1w-1Date
• ' TOWN OF NORTH ANDOVER
. q F.0
6 .
$
Certificate of Occupancy q
� Building/Frame Permit Fee
r
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Checkap- d��
G IJ J l Building Inspector
03-24-' 14 08: 46 FROM- 9786814980 T-778 P0001/0001 F-741
1AIVOOAV
9a
Greater Lawrence Community Action Council,Inc. 3331 .
Weatherization Assistance Program „1? r �c� -� CUP
303 Essex Street
Lawrence,MA 01840
WORK, PFRMIT
N.A < fe- A-A.K Certify that I am the owner/authorized
Agent for the property at-. /j�
(Address)
I further certify that I have given my permission to allow work on the property
lasted above in accordance with the following provision-,
1. Weatherization
20 -
74-
-- --- heating System Work
and such outer particulars as may be attached to this agreement.
Sigurd: Date: j
Owner/Autboriae&A
DEC 19 2013
03-24-' 14 08;52 FROM- 9786814980 T-779 P0001/0003 F-742
Client Lise Knaakergaard
address 105 High St
city/town North Andover
contractor
1-WEATHERSTRIPPING/CAULKING QUANTITY TOTAL AUDITOR NOTES
Door Kits Q-Lon or Equiv. 3 138.50
Door Sweeps(Regular) 0 0.00
Door Sweeps(Automatic) 3 69.00
Reglaze Windows/In.inch 0 0.00
Window.Wealhstr Schlegal per side 0 0.00
Tenmat Recessed Can Cover 0 0.00
Attic/Basement bypass sealing man/hr 3.5 210.00
Attic sealing with 2-part foam man/hr 0 0.00
SUBTOTALS 415.50
2A.INFILTRATION/INSULATION AUDITOR NOTES
Domestic pipe Hot Water Tank 1 st 6' 1 15.78
Sill Insulation R-19 CF 0 0.00
Sill Two Part Foam w/Fiberglass Batt 0 0.00
Drape Perimeter R-5 Anch.Sq.ft. 0 0.00
Perimeter 2"T-max or equivalent foam board sq.ft. 0 0.00
Drape DOOR R-5 or T-max or equivalent on door. 0 0.00
Tape Joints(Alums Grip only)per hr. 0 0.00
Duct Insulation&Tape sq.4t.R-5 0 0.00
Rigid Foam Board Anch. 1"per board 0 0.00
Hydronic pipe insulation to 1"R-5 0 0.00
Hydronic pipe ins,1.25"-1.5"R-5 0 0.00
Steampipe Ins.tol.25"iron pipe R-5 0 0.00
Steampipe Ins.1.5"-2"iron pipe R-5 0 0.00
Steampipe Ins.3"iron pipe R-5 0 0.00
Air Conditioner Meeting Rail 0 0.00
Air Conditioner Cover 0 0.00
Air Conditioner Cover Special Order 0 0.00
SUBTOTALS 15.78
2B.INSULATION AUDITOR NOTES
Open Unrestricted R 49 0 0.00
Open Unrestricted R 38 0 0.00
Open Unrestricted R 30 0 0.00
Open Unrestricted R20 0 0.00
Open Unrestricted R 10 0 0.00
Restrict FL/Sloped R 30 0 0.00
Restricted FUSloped R 20 0 0.00
Restrict FL/Sloped R 10 0 0.00
R-19 FGB open rafters/walls/kneewalls 0 0.00
R-11 FGB open rafters/walls/kneewalls 0 0.00
Attic Stairs(stainvell 8 common wall) 0 0.00
Cover Pull Down Stairs Thermadome 1 180.00
Site built pull down stairs 2"foam box 0 0.00 2-Floor hall
03-24-' 14 08;52 FROM- 9786814980 T-779 P0002/0003 F-742
Attic/Kneewal Floor Transition.Dense pack cellulose 0 0.00
W,S,Hatch Q-Lon or equal 0 0.00
W.S.&bat Hatoh R-30/Q-Lon or= 0 0.00
r
KneeWall R-12 Cell behind Per.Memb 0 0.00
Open Rafter R-20 Coll./w poly 0 0.00
Open Rafter R-30 Cell,/w poly 0 0.00
Basement Overhead R-18 fiberglass 0 0.00
Basement Overhead R-30 fiberglass 0 0.00
Crawlpace Overhead<4'high R10 0 0.00
Crawlpace Overhead<4'high R30 0 0100
Garage Ceiling cavity filled w/cellulose 0 0.00
Wood,Shake,Clapboard,Shingles Vinyl 1304 2334.18
Asbestos(single nail)/Asphalt 0 0.00
Asbestos(doub.Nail)/Aluminum 0 0.00
Brick/Stucco 0 0.00
Vinyl over Asbestos 0 0.00
Multilayered 3 or more layers 0 0.00
Drill rough plaster or finish wood plug 0 0.00
Drill finish plaster 0 0.00
Test Drill Walls(all 4) 0 0.00
SUBTOTALS 2314.16
2.INSULATION TOTAL 2A.t2B. 2528.84
3.STORM WINDOWS/DEADLITES AUDITOR NOTES
Plexiglass up to 88 0. 0 0.00
Additional per UI over 88" 0 0.00
Other(Negotiated Price) 0 0.00
SUBTOTALS 0.00
S.OTHER MATERIAL AUDITOR NOTES
Ridge vent In H. 0 0.00
Vents Gable rectangular 0 0.00
Varipitch Vent 0 0.00
Vent Roof 135(1 sq h NFV)Large 0 0.00
Vent Roof 866(.4 sq it NPV)Small 0 0.00
Vent Soffit Rectangular 0 0.00
Turbine Vents All 0 0.00
Stack Vent 0 0.00
Propa Vent 0 0.00
Permable House Wrap 0 0.00
Vapor barrier 0 0.00
Energy Star R-4 Rigid Vinyl Rept 04-101 U.I. 0 0.00
SUBTOTALS 0.00
8./7.E.C.MATERIAULABOR 2845.44
Page 3
8a. HEALTH&SAFETY JAUDiTORNOTE6
03-24-' 14 08:52 FROM- 9786814980 T-779 P0003/0003 F-742
Dryer vent w/exhaust duct Heartland 0 0.00
Dryer Tran6ilion Duct only 1 40.00
Blower DVITest Pre Post 0 0.00
SUBTOTALS 40.00
8b.REPAIR MATERIAULABOR AUDITOR•NOTES
Basement outside door only 0 0.00
Basement outside door w/jambs 0 0.00
Door Repl pre hung 32-36"Steep"w/Lite 0 0.00
Door Repl interior solid core 28-32" 0 0.00
Poor Repl pre hung 32-36"wood-w/Lite 0 0.00
Window Replacement w/SIR less than 1 0 0.00
Basement Window Repl.Awning/Hopper 0 0.00
Basement window Repl.With a frame 0 0.00
Locksei(door)Schlage or equal 0 0.00
Repair/Refit Door 0 0.00
Replace Side Stop 0 0.00
Replace Casing 0 0.00
Glass Replacement to 64 u.i. 0 0.00
Glass Replacement per u.i.over 64 0 0.00
Sash Sidelock/'fop Replacement 0 0.00
Threshold(Wood) 0 0.00
Threshold(Aluminum) 0 0.00
Slide BOILS 0 0.00
Plug Plate Cover 0 0.00
Cut/finish attic-kneewall access 0 0.00
Cut/close attiakneewall access 0 0.00
Labor Rate Hours 0 0.00
Permits/Fees(Wap only) 1 36.00
SUBTOTALS 36.00
TOTAL REPAIR+HEALTH&SAFETY 76.00
GRAND TOTAL WORK ORDERS (A) 4337 3021.44
Lis@ Kneakergaard
105 High St
North Andover
Any alterations or deviations from the above specifications involving
extra costs must be cleared in writing before installation.
The Work Order must be complete within 15 working days from acceptance
date below:
CONTRACTORICOMPANY: 0
ACCE PTANCE:Company/Contractor
AUTHORIZED SIGNATURE: Date
AGENCY APPROVALS:
CTI Authorized Signature: Date
GLCAC Authorized Signature: Date
09610 Yiv + !V
1 ,y31 � 7 JI Alt^ 3i .r`:t8'e4t br tl�i�C 1
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The Commonwealth of Massachusetts -
Department of Industrigl Accidiints
Office of Investigations
600 Washington Street
.Foston,MA 02111
www.mass gov/dra
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le:sibk
Name(Business/Organiyation/lndividual):
Address: 2;P
City/State/Zip: 4411 e o t n ' Phone#: 211-"/7S"--Z2l"1`
Are you an employer?Check the appropriate box: Type of project(required):
_I.Kp y to er I am a em with 4. El am.a general contractor and I
._� 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7. ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me,in any capacity. workers'comp.insurance, g, ❑Building addition
[No workers' comp.insurance 5. ❑ We area corporation and its
officers have exercised their 10.n Electrical repairs or additions
required.] o
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurancerequired.]i employees.[No workers' 13.0 Other
comp.insurance required.]
!Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
1'-Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employep that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name%
Policy#or Self ins.Lie.#: 40 l✓C `(&23 7 G Expiration Date:
lob Site Address: lib City/State/Zip: �/ar714 WZ�Y 191f �
Attach a copy of the workers'compensatlowpollcy declaration page(showing the policy number and expiration date).
Failure to secure coverage as regniredunder Section 25A ofMGL o. 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 fins
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
X do hereby cert&under thepains andpenalties ofperfury that the information provided above is true and correct -
Si afore• y //rte Date:
Phone#• Zo �t-
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#:
Information and Instruction
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,•
express or implied,oral or written."
An employei 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 of public 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'compensailon 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 an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. AIso 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 permit/license number which will 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 aid fax number:
The CoUuAonwealthofMassachv&e,#S
Mpatteut ofZnduMal.Acciclotts
Off toe Qf1AVestzgatj0A,% •
600 WasWngton Stroet
Boston,MA.02111
TO.#617-727_4900 ext 406 or 1-877:1VIASS. E
Revised 5-26-05 Fay,#617-727-7749
www'.xpaagovfdaa
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V 1998.2010 ACORD CORPORATION All rights reserved,
ACOTID 2S{201"S) The AC ORD name and logo we Tegisteroomarks of ACO RD
Fh4Pe: F3 : E-Mail:
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CERTIFICATE OF LIABILITY INSURANCE 3r9r1n
TO$CERTIFICATE IS ISSUED AS A MATTER OF tWORMATION ONLY ANO CONFERS NO MHNTS UPON THE CEATiRCATE"OLDER.Y1fIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW., THIS CERTIFICATE OF INSURANCE 'DOES MDT CONSTITUTE A CONTRACT BETWEEN THE ISSUING DI.SURERJS}, AIRHDfIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
h�tTtAN1`, n 1Ae ceruhCat9 holder 18 an ADDIRONAL INSURED,the po!C 9g)rrlllst pe andoras+d. !t SUHii0�A1UON dS U1'AIVEO,su t to
the terms end conditions of the Pollcy,certaln Policies may r$Wkrq an endorsement, A statement onihl s c9riilissate sloes not confer rights to 1119
ceF1I6C to holder In lieu of such endorsmwol
__ _ - --
wtaatc� NuaL,. __Paul T Murvhv
Paul T Murphy Insurance Agency PHONt `
Bro
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Maiden, MA 02148 aulP tminsurance.com
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28 Hamilton St INSUrIl�IS< .. `
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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MOCATEO NOTWiTH,$TANDLVG AW REQIjIREfAF_?IT.TEM/OR CONDITION OF ANY CONTRACTOR 0`HER DOGt-INEWT VIN RESPECT TO WHICH THIS
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Insulation-GLAC Inc,, Community Teamwork Inc, NGRID Corporate Services LLC., DBA !National Grid
DBA Boston Gas Co DBA Colonial Gas Co DBA Essex Gas Co, NSTAR, ABCD Inc and Action Inc are
listed as additional insured on GL perform 30 AP 2037 03/08 Construction Contracts.
Coveraae is subtest to ooliev terms conditions and exclusions.
CERTIFICATE MOLDER CANCELLATION
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Energy Pror,Nraeas
45 Kirk St. 2ad FIr AUiWJ(Tt&b MI'MOMIA(it
Loren, !CIL 01852
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rr 1988-2010 AC'ORD CORPORATION, All rights reserved.
ACOA 0 25 4201 C1arOS) The AC ORD no me and Ingo are Feglsterod marks of AC 0 RD
phdate: Fag.: E-Mail:
c1pRTH
Town of - ., Andover
No.
61- 14T
o hver, Mass,
cocNicNlwlc.c �1'
S U
BOARD OF HEALTH
Food/Kitchen
PERMIT T LD Septic System
�y �_ BUILDING INSPECTOR
THIS CERTIFIES THAT .......:Lal ....... .. 1('4.�,........... .........� .... .... ....................................
Foundation
has permission to erect .......................... buildings on ...............�.� ..... ...�5.. .....................
" Rough
to be occupied as ..��sS-.✓..�? .............�'......i;"?�;!rL.�!�.�'�r�.....:....................................... Chimney
provided that the person accepting this permit shall 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
Rough
VIOLATION of the Zoning or Building Regulations Voids this Permit.
Final
. - PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIO TA S Rough
Service
.................... .......... .......... Final
BUILDING INSPECTOR
GAS INSPECTOR
Occupancy Permit Required to Occupy Building Rough
I
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.
Smoke Det.
Date
ORT"
TOWN OF NORTH ANDOVER
0
PERMIT FOR PLUMBIN
-TACHUS
This certifies that . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . . . .D . . . . . . . . . . . . . . . . . . . . . . . . . .
plumbing in the buildings of (.0.1 . . . . . . . . . . . . . . . . . . . . . . .
at. . . . .C-1..... . . . . . . . . . . .. North Andover, Mass.
Q-
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Fee. 3. :?—. . .Lic. No. �.O . . . . . . . . . . . . . . . .
PLUMBING INSPECTOR
Check #
6753
IVIK55ACH,USETTS U OFF—__
(Print or T pe) UNIFORM APPLICATION FOR.PERMIT TO DO PLUMBING
INA ass. Date t'i a�a
_ #Building Location KOwy�o
Type of Occupancy
New❑ Renovation D Replacement
Plans Submitted: Yes D No o
FIXTURES
B.P. # SEWER #
SEPTIC # .
z z
11--.. z Z
W LLJ
Y L } O Q Ln j N
JO n w IIz to ¢-.. w N _ z O Z to W W W
to = U u_ Z a z a
z � m Ul, W �- Q � LnLn
_ � . w vWi 0 F ¢ N D a Z a
cn D 2 to Q m p O
SUB-BSMT u-
BASEMENT
1ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FL00
istalling Company Name I
Check one:
ddress Certificate
ell .01
❑ Corporation
:C
-isiness Telephone 2 r ❑ Partnership
ime of Licensed Plumber or Gas FittertrFirm/Co.
NSURANCE COVERAGE:
have a current li bllity insurance policy or its substantial equivalent, which meets the requirements of MGLCh. 14
Yes 1 No . 0 z
IF you have checked es, please indicate the type of coverage b checking the g y 9 appropriate box.
liability Insurance policy� Other type of Indemnity D Bond ❑
IWNER'S INSURNACE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter
42 of the Mass.General Laws, and that my signature on this permit application waives this requirement.
ignature of Owner or Owner's Agent Check one:
Owner 0 Agent ❑
reby certify that all of the details and-information I have submitted (or entered)In above'application are true and accurate to the best of
Knowledge and that all plumbing work and Installations performed u r the permit issued for tL-v
ion will be In compliance w(th
ertinent provisions of the Massachusetts State Plumbing Code and h to 42 r e G oral La
By
Title Signa re of Licensed Plum sr
City/Town
4PPR0VED(OFFICE USE ONLY) Type of Licenser Q,Ntarster .
0 Journeyman
License Number hh 3
c"7
a'
BELOW 1011 OFFICE USE OMLV
FINAL INSPECTION$ iKETCMEs y PIIOWIESS INSPECTIONS
FE[
N0. ,
APPLICATION FOR FIERII1T TO 00 FLUMBINO
NAVE a TTFII OF IMILOINO
LOCATION Of BINLOINO
FLU IV I
PIMIMT ONANTEO
OATS
� !NO Nli►ECTOII