HomeMy WebLinkAboutBuilding Permit #765-14 - 73 BERKELEY ROAD 4/29/2014TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: ` Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this RaLge.
LOCATIONS a --
IT w� �q
�PROPERTrY ®UVNER_
Prmt ,100 Year Old Structure^ _
LOA ZONING�CT _Historlc1District
__Machine Shop Village:
noN
TYPE OF IMPROVEMENT,
PROPOSED USE
Resi ntial
Non= Residential
❑ New QjAding
One family
❑ Ad ' ion
❑ Two or more family
El Industrial
11eration
No. of units:
❑ Commercial
-WRepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
❑ Other
`Septic ❑ 1JVell j
❑uFloodplam O Wetlands
❑ 1lVatershedtDi'strict
j❑ .Water/Sewer
y
x
DESCRIPTIONSWLAUARK TO gE"RERFORF4ED:
Please Type or Print Clearly)
OWNER: Name:
Phone:
S
ARCHITECT/ENGINEER
Phone:
Address: Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ FEE: $
Check No.: ��, Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have accessl4o the gggranty fund
Plans Submitted L.
Plans Waived ❑
Certified Plot Plan ❑
ped Plans ❑
Location e2 1
No. o t Date l nJ
r r
o - TOWN OF NORTH ANDOVER
e Certificate of Occupancy $
Building/Frame Permit Fee
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
27510
Building Inspector
Plans Submitted ❑
PlansWaived-11 .Certified Plot Plan ❑ Stamped Plans ❑
_TYPE QF= SEWERAGE MSP.OSAL"
..
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well
Tobacco.Sales
,•Food Packaging/Sales ❑
Private (septic tank, :etc._
Per DOmpster on Site ❑
THE_ FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT-
COMMENTS
EVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
HEALTH
COMMENTS
DATE REJECTED -
_ ❑El
DATE APPROVED
Reviewed on Signature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decisionfreceipt submitted yes
s Planning Board Decision: Com
Conservation Decision: :Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW TovYi'. Engineer: Signature:
Located 6M USgOOO Street
FIRE DEPARTM� NT Ternp Dumpster on site
yes no
Located at;124,Mair Street r ;, .w
COMIVI.ENTS•}:�-
--Dimension
Number of Stories: Total square feet of floor area, based on Exterior dimensions._
.Total land area; sq. ft.:
ELECTRICAL: Movementof Meter location, mast or service drop requires approval of
Electrical Inspector Yes No
DANGER.ZONE LITERATURE: Yes N®
MGL -Chapter -166 Section 21A —F and G min.$100=$1000:fin.e
NOTES and DATA — (For department use
El Notified for pickup - Date
Doc.Building Permit Revised 2010
N
Building Department
The fo0owing19,41ist of the requited -forms #o be filled out for the appropriate. permit .to .be obtained.
.Roofing, Siding, Interior Rehabilitation Permits
❑ ' Bailding Permit Application
❑ Workers Comp Affidavit
❑ Photo Copy Of H.I.C. And/Or C.S.L Licenses
o Copy of Contract
Li Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
E: 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
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
o Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
o Engineering Affidavits for Engineered products
All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
NOTE:
La Building Permit Application
o Certified Proposed Plot Plan
Li Photo of H.I.C. And C.S.L. Licenses
❑ 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
❑ Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
I cases if a variance or special permit was required the Town Clerks office must stamp tlie.decision from the Board of Appeals
the apo• -al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
t be subm.tted with the building application
Doe: Doc.Bui!,ding Permit Revised 2012
V
r
L
Ja
ua,
2
LL
O
a'
CO
,+U_+
Y
O
LL
E
v
T
Vl
N
V)
0
a
N
Z
Z
m
c
O
N
O
LL
L
O
d'
C
L
U
_
O
LL
0
z
?
m
J
a
L
O
K
_
LL
0
wa
Z
J
v
W
J
w
L
O
u
N
_
LL
O0
ui
NQ
z
Q
L
O
d'
_
LL
z
.
w
0
W
LL
N
O
m
O
Z
++
a�
V)
.,.;
N
Y
E
V)
N
CL
y
U)
c
tm
w
tm
m
0
_
O
N
d
t
O
Z
O
s
O
2
Z
G
Z
W
w
CLX
ujW
m
0
W
CL
CO
z
0
IM
r
uiar
O
U
Z
J
Z. -
C:
w
5
O O
N
Cc O
•CL
_C
L
as
CLcc
��
a¢
g
'y
0 0
CD
o�
E Q.
Q
L �
�_.�
w c,
E0
i tm
C
0
_ �
O = _c
O O
.�
V L
:
v N
Q. J
N
O O
L m
>
-a—
N i
N
_
O
y N
= d C
LL.4-115
— mo
c
�
cc
N
CL
y
U)
c
tm
w
tm
m
0
_
O
N
d
t
O
Z
O
s
O
2
Z
G
Z
W
w
CLX
ujW
m
0
W
CL
CO
z
0
IM
r
uiar
O
U
Z
J
Z. -
C:
w
5
N
Co
Z
��
CL_-
rn o
g
'y
CD
o�
Q
�_.�
w c,
.
.:.—m6
v
O = _c
.�
0
CL
N
O O
ujcL=:E.2.:.
-a—
LL.4-115
N =
W
U
E
OCL
O �,
_
O
s
O
F --U
CL0
N
CL
y
U)
c
tm
w
tm
m
0
_
O
N
d
t
O
Z
O
s
O
2
Z
G
Z
W
w
CLX
ujW
m
0
W
CL
CO
z
0
IM
r
uiar
O
U
Z
J
Z. -
C:
w
5
next step living
WINDOWS CONTRACT
.,=,
NSA. Copy
Saturday, February 08, 2014
750
This Agreement is entered into on the date shown above and is by and between Edwin ana Charming Storey 1-5s
having a mailing address at 73 Berkeley Rd, North Andover, MA (the "Owner") and Next Step Living Inc.,
21 Drydock. Avenue, Boston, MA 02210 ("NSU').
1. THE WORK AND THE MATERIALS.
NSL shall perform all work and supply all materials described on Exhibit A* (*Next Step Living window proposal) attached to
this Agreement and will be responsible for any and all equipment's, supplies and appurtenant items as may be required and
necessary to perform all work described on Exhibit A and any performance reasonably inferable from it, including cleanup
associated with NSL's work (the "Work").
2. CHANGES/PERFORMANCE OF THE WORK.
2.1 NSL will not make any changes in the Work other than those described on Exhibit A, unless agreed to in writing by the
Owner.
2.2 NSL represents and warrants to the Owner that (a) the materials and equipments furnished under this Contract will be of
good quality and new, (b) that the Work will be free from defects, and (c) that the Work will conform with the description of the
Work described on Exhibit A.
3. TIME FOR PERFORMANCE.
NSL shall ensure the Work will be done in a timely manner and will ensure that the Work is done diligently without delays or
interruptions until completion. If the Work is to be done in stages, the previous sentence shall apply to each such stage.
4. TERMS OF PAYMENT.
The Owner shall pay NSL the balance upon the completion of the Work described on Exhibit A.
5. INSURANCE AND LICENSING.
NSL represents and warrants to the Owner that NSL is validly licensed and that NSL has all insurance required by applicable
law and normally maintained by prudent contractors in NSL's field, including, but not limited to, workmen's compensation for
all employees who will perform the work.
�r
6. QUALiTY OF WORK.
NSL agrees that the Work will be performed in a good and workmanlike manner, and that NSL will ensure repair and
replacement, at its own expense, and promptly upon Owner's request, any defects in workmanship and materials provided by
NSL or subcontractors of NSL which appear up to one (1) year after the date of final payment for the Project to NSL or within
any longer period as permitted or required under applicable law.
7. GENERAL PROVISIONS.
7.1 Any disputes which may arise between the Owner and NSL shall not impede or interfere with the diligent performance by
NSL of the work.
7.2 This Agreement shall be construed in accordance with the laws of the State of Massachusetts.
7.3 NSL may not assign this Agreement or any of its rights to payment without the Owner's prior written consent.
Page 2
" next step [iving
8. PRE-EXISTING CONDITIONS & PROPERTY PROTECTION
8.1 NSL shall not be responsible for any damages as a consequence of the Work performed in the home due to pre-existing
conditions. These conditions include but are not limited to cracked or broken drywall, old piped and fittings, rotting wood,
faulty electrical wiring, etc.
8.2 NSL reserves the right not to perform work upon the discovery of asbestos, mold, or any other potential health risk. In this
event, the customer is responsible for removing the hazardous materials and all bills for services shall be paid immediately.
Work cannot resume until remediation is complete.
8.3 NSL will make best efforts to protect any property of the customer, but it is the customer's responsibility to remove or
protect, including dust protection, any personal property including the home itself. NSL will not be responsible for damages to
or losses of the above mentioned property not properly protected prior to the commencement of work.
9. PAYMENT
9.1 Total estimate amount is $ 17,575.38 . Customer shall pay 1/3 of estimate amount, or $ 5,858.46 upon acceptance
of this contract and final payment of $ 11,716.92 will be due upon completion.
9.2 If customer is using financing. Down Payment deposit due at signing. Pending funding approval, final payment will be due
upon completion.
Total cost of project: $17,575.38
Deposit required: $1,200.00
Balance due upon completion: $16,375.38
If using the Heat Loan for this purchase and installation, this contract is contingent on the customers receiving the Heat Loan
authorization and approved financing by the customer's lending institution.
This Contract, including the documents incorporated into this Contract, forms the complete integrated agreement between
Contractor and the Owner. The parties represent and warrant that in executing this Contract, they are not relying on
representations other than as expressly contained herein. There are no other terms or conditions that form a binding agreement
between the parties other than this Contract and its incorporated documents. This Contract supersedes all prior agreements
between the Owner and Contractor and may not be altered absent a subsequent written agreement signed by both parties. Both
parties have reviewed this Contract and represent that they understand and agree to all terms herein.
We have ead this Contract and agree to its terms.
Edwir ar ha a ig Storey
t.
By the Owner, (Signature)
X/, Z" "/z' Gfr��-�
t ten Living 16'i-c.-
rtc.
2/8/2014
Date:
2/8/2014
Date:
Page 3
omu
14, qj
�$�vG533rf�dix'
t7a� rT t°i3'.''a r3 S�.`��' i
j03.L�3a
NVork-ei °s' C0M-P-,R5,u tit I-
��me (BnsLnes. �
/Orguuc,`U "d�sal}: ,
t ..
6.
ne
/Zip:
V Type of prOIert
Are au eItloyer°► C>meclt ap rod I a, a general condor and 11`�ew cantn action
1. I am a employerwrth . Rnodelirag
have hued the sub -contractors
employees (full and/or part-time).T listed.on the attached sheet. 7. ❑
2. I am a.sole proprietor or partner- Tl es -contractors ]rave & E] IDernoii'dcn
ship and have no employees employees andhave workers' U, [.Building add-, ion
working forme m ady capacity. comp .insurance lal,[] Plectricai 3eM17S or additiers
[No workers' comp. j1rst ince 5. [] We are a corporation and its I
regwred ] s repair o- additions
officer have ex'srcised their t l.❑ Plusbinb
3 . [] 1 am a homeowner doing all work right of exemption per MGL 12.R Roo r -pairs
l o workers' comp: �d we have no
mysei � � c. 15 § 1�4)� _ .. __..--�--
insm--ance required ]. i CDT loyees. [ATo- workers' _
comp. insurance required.]
Y applicant that checks bo #i mus. also fill out the eeeha e�ing �l work and then twe outs9de con�aet tars m� st sub -ml. a Dei o da ,it indicafimg such.. .
t Hoaneo�rrners who submiF this'affidavit. indicating they
am t `ntocs that"check this box must attached an addidanal sheet_ shotnrmtwornama'6tthe sub -c.
crop. y p bei and state vahetliei or not Those entities have
G .
employees if the sub contractors have employees, they must provide their .�® ee$. Below is thepm�gc?' and 1®b site
I a'aan ey�pl�yer Ma l i� provid ng wor°keW �o ensaadon irasuffiaace fa9P gray err�p 9'
inj®i'r Md on.
Insurance Company Name: � , 1 X F�`phation bate:
—
Policy # or Self -ins. Lic. #:
��-t ---
Job Site Address:
B City/Staie/Zip:
the ®tic u>m�hee and cxpi�ti®a date).
�ett�ch a copy. ®f the wo>rketrs' compeosatnom po�acy a�ecla �a®>o.page Qslno g policy penalties of a
Failure to secure coverage as required under 5ec� n s5 X11 e it penaltiof MGL c. DY es in tt�a formleadto e of a 5TGP WORK ORDF-R and a filrf,
fine up to. $1,500-06 and/or oige•.year inipnsonm t,
of Trp to:$250.00 a day against the vi6lator. Be �d�'ised that a copy of tltis state ent -may be forwarded to the ®fiice of
e verification..-- ---_
Investigations of the DU for in
coverag -�-- - —
red�cr t°fie into➢ dlEQd p88llaTi�ies iL�p'E.�a4e mart &e inforr8'➢artac9 ided arkr®➢'u is 4'(Q36re c6�a-we el
I d® Dn�reh .,�esJ p
p�
Offtrial use only. Dar not write in this area, to be cotnapdeted 6y city yr town aifficiraL
Periomiaicense #
City or'1c
Iss>mi g Authority (circle one):
I . Rio of wealth 2. B➢ti9di�ag Department 3. tLity! bo a clerk 4. Electrical Inspector 5. Plu➢�albimg lt3s>gector
L_6. ®ther:
PaMw "�w
M
A-1
Ya
Yr x
nyi
..............
ac & CERTIFICATE OF LIABILITY INSURANCE 03-12-2014
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 INSUREO, thepolicy(ies) mustbe endorsed. If SUBROGATION IS WAIVED,
subject to the terms and conditions of the policy, certain policies may require an endorsemenL A statement on this certificate does
not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
CCNTACr
NAIAE:
PHONE FAX
aCN.. CeI: Ala No
CARELLAS INS AGCY INC
207 PARK AVENUE
WEST SPRINGFIELD, MA 01085
` Mal
INSURE R(S) AFFORDING COVERAGE NAICi
INSURER A : TRAVELERS PROPERTY CASUALTY COMPANY OF
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑ OCCUR
LRIpMIT APPLIES PER.
POLICY JEOT LOG
AMERICA
INSURED
:NSURER B
CRAIG RONALD DBA CRAIG
WINDOWS
:NSURER C :
NSURER c
PO BOX 292
INSURER E:
HUNTINGTON. MA 01050
PERSONAL S AOV W.,URY S
NSURER F.
^rIUMOsncm r CRTIrIrATF U"FARFR• REVI4Ie)N NHIURER!
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
LTA
TYPEOF INSURANCE
ADD
SUB
YIVD
POUCY NUMBER
POLICY EFF
MIWT)O/YYYY
XP
POLICY EO
OENERALLIABIUTY
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑ OCCUR
LRIpMIT APPLIES PER.
POLICY JEOT LOG
EACH OCCURRENCE S
RE NTEO g
:7AIAAGETOSF
MED EXP (A oneueuwnl S
PERSONAL S AOV W.,URY S
OENERALACGREWE S
GENLAGOREGATE
PRODUCTS - CCMPAOP AGO S
S
Atr
MOBILE LIABILITY
ANY AUTO
SCHECULEO
ALL OWNED AUTOS AUTOS
HuiEDAUTOS AUTOS NON-OVINEp
5.P1A,8C1NEgS1NGLE LIMIT S
BODILY INJURY (Per pewsor) S
BODILY INJURY (Per eaeiderAl S
OP R VQAMAOE g
Ff
5
UMBRELLA LIAB
EXCESSUAS
OCCUR
C.IADAS-MACE
EACH OCCURRENCE E
AGGREGATE S
pEp RETENTIONS
S
WORKERS COMPENSATIONX
AND EMPLOYERS' LIABILITY Y N
ANY PROPRIETORIPARTNEPJEXECUTIV
OFFICERAVEMBER SXCLUDcD7
(MandataylnNH)
'i yes, describe under
DESCRIPTION OF OPERATIONS below
N / A
7PJUB
56877428
03-15-2014
03.15-2015
WC STATU- OTH-
TORY LOUTS ER
E.L. EACH ACCIDENT $100,000
F.L. DISEASE - EAEEMPLOYEE $500,000
E.L. DISEASE - POL.CY LIMIT $100,000
DESCRIPTION OF OPERATIONS I LOCATIONS/ VEHICLES (ANach ACORD 101. AddalonaT Remarks ScRodub. 11 maro spam in requlmd)
THE WORKERS' COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR CRAIG, RONALD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES
CANCELLED BEFORE THE EXPIRATION DATE THER'.
NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010105) The ACORD name and logo are
� \ �
#.�
.�
. S22
. �■A
.. .
//
zz
t
■ .
^
2 12
§
� \ �
...7«
§
q&&Q
\{
§ t f.
o
/
k
E m
R
J
0
c \
Q
L
e
. i
n
a
Q
0
■
a
.
Date.///� 4.7
q
NORTH
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .•.....':,.37.- .bI . ............
has permission to perform .......... — ...................
plumbing in the buildings of...........
at NortlV'Andover, Mass.
F e e .... Lie. No6*
. ......... I a........... .
Pt-UMBIN. � NSPECTOR
Check #
75,53
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,". SSA 11
S
/f Date /o-ay�7
Building Location 7.3 L50T,�/ 9, flo • Owners Name /�� /ye U�j�es/ Permit #
Amount
Type of Occupancy
New 1:1 Renovation M Replacement ID Plans Submitted Yes 11 No ❑
(Print or type) T / Check one: Certificate
nn
Installing Company Name CJ l 6 PIU/i�l�% �` ai.�S, Corp.
Address /y19 I�J- Partner.
4L"41 A111 03 4
Business Te ephone 4!5�,3 - 97/-7 Firm/Co. s6,71'ZI
Name of Licensed Plumber: �TC/sllljaa- (! 04'01jta r/
Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy [a 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 F1
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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massae use s State PI Code and Chapter 142 of the General Laws.
BY gna u e 3T Mcensecium er
Type of Plumbing License
Title I
City/TownLicense lNumoer Master ❑ Journeyman n 1"
APPROVED (OFFICE USE ONLY t�1
�J
0-
i
(Print or type) T / Check one: Certificate
nn
Installing Company Name CJ l 6 PIU/i�l�% �` ai.�S, Corp.
Address /y19 I�J- Partner.
4L"41 A111 03 4
Business Te ephone 4!5�,3 - 97/-7 Firm/Co. s6,71'ZI
Name of Licensed Plumber: �TC/sllljaa- (! 04'01jta r/
Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy [a 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 F1
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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massae use s State PI Code and Chapter 142 of the General Laws.
BY gna u e 3T Mcensecium er
Type of Plumbing License
Title I
City/TownLicense lNumoer Master ❑ Journeyman n 1"
APPROVED (OFFICE USE ONLY t�1
�J
0-
a
:.RTH
e1: � o ... .
NORTH
°f ",ao
o? ` TOWN O ANDOVER
;- PERMIT FOR GAS INSTALLATION
This certifies that .. ................. .......
has permission for gas installation
in the buildings of ............ `....... ................... .
at .. ,�. . ��^'�..orth Andover, Mass.
FeeA'. Lic. Noky�...f ,� ......... .
GAS IN$ E6fOR
Check # /� a.•
6200
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date za:_.2
NORTH ANDOVER,, MASSACHUSETTS ,
Building Locations 73P��/ �</ /Y� Permit #
Amount $
Owner's Name1,6fve e,
�*
New D Renovation D Replacement D Plans Submitted
D
(Print or type) Check one: Certificate Installing Company
Name �-�%�� ��i/hiit� fi` yPGiTii�� D Corp.
Address //9 . 41177zt Jnr rc/ D Partner.
T . it1/1 0.1.5r'3-3
Business lie ep one D Firm/Co. SI? -71-21
Name of Licensed Plumber'or Gas Fitter �ds/�UGI (7GZUCf�eet!/
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 NoO
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability Insurance policy ®' Other type of indemnity D Bond
Owner's Insurance Waiver: l am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
I herehv rprti Ai tint oil -f+k- A- -.1.. —A
-_ ___ _ _ __._ __ .... _.. .... ................ kV, r„«,CUA In aoove appucatlon are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach}Iset5B State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town;
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
D Plumber 24�as-0
Gas Fitter License Number
Master
Journeyman I
�
a
w
�a
C7�
�
w
�
o
w
w
=
o
z
F
aG
za
z
F
z
F
a
a
F
a
o
m
z
z
o
0
�,
w
x
O
x
3
A
C�7
U
a
>
A
a
F
O
SU B-BASEM ENT
BASEM ENT
/
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7 T H. F L O O R
1
#14
1f
8TH. FLOOR
(Print or type) Check one: Certificate Installing Company
Name �-�%�� ��i/hiit� fi` yPGiTii�� D Corp.
Address //9 . 41177zt Jnr rc/ D Partner.
T . it1/1 0.1.5r'3-3
Business lie ep one D Firm/Co. SI? -71-21
Name of Licensed Plumber'or Gas Fitter �ds/�UGI (7GZUCf�eet!/
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 NoO
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability Insurance policy ®' Other type of indemnity D Bond
Owner's Insurance Waiver: l am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 0 Agent
I herehv rprti Ai tint oil -f+k- A- -.1.. —A
-_ ___ _ _ __._ __ .... _.. .... ................ kV, r„«,CUA In aoove appucatlon are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach}Iset5B State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town;
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
D Plumber 24�as-0
Gas Fitter License Number
Master
Journeyman I