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HomeMy WebLinkAboutMiscellaneous - 103 OLD VILLAGE LANE 4/30/2018-_ __._. ���G� ����Pd4 ot�0 �i 110, Date ... ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION !This certifies that ,/n6/2;W.r) ... Z clevz .... has permission for as installation ... 9 .. .......�.......e$........................ inthe buildings of ................................................................................................................... �4,0 ................ .. North v r, Mass. Fee.;.2,1^ ...... Lic. N .. .......... G S INSPE TOR Check # S, /- 6 tj G TYPE OR PRINT CLEARLY UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY o (' h A U� l _� MA DATE [ PERMIT # JOBSITE ADDRESS OWNER'S NAMES L t�----�---- OWNER ADDRESS TE`t—s— — FAX ��m, OCCUPANCY TYPE COMMERCIAL F_Jl EDUCATIONAL NEW: EJ RENOVATION: El REPLACEMENT: El APPLIANCES 7 FLOORS- I BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER RESIDENTIAL PLANS SUBMITTED: YES NO0 10 11 T12 1 13 1 14 — -- -- - INSURANCE COVERAGE 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES1] NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [P OTHER TYPE INDEMNITY ® BOND F OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [j AGENT El SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code —and -�Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEAl /l i/�,P � [lyl j LICCEN—SE—#SIGNATURE MP [j MGF 0 JP [4 JGF � LPGI � CORPORATION ©# --� � PARTNERSHIP ®#= LLC [I#= COMPANY NAME: �,� (/n .�+ ,reLil�ADDRESS/, STATE _ �/I ZIP D TEL C} (0 CITY AT - - -I - IC n FAX[:= CELL =EMAIL_ 9� o El z d� ®:oGil The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia ' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. Workers Comp Please Print TO BE FILED WITH THE PERMITTING AUTHORITY- TO Name (Business/OrganizatiOlAndividud):AnLI, Address: �� W ` -/ PITA City/State/Zip: W nil4 Phone #: Are yon an employer? Check the appropriate box: employees (full and/or part-time).* l,❑ I am a employer with 2.I ip and have no employees working am a sole proprietor or partnershforme in any capacity. [No workers' comp. insurance required.] r doing all work myself. [No workers' comp. insurance required.] t 3.[] I am a homeowne 4.E] I am a homeowner and will be hiring contractors to conduct all work on my property. I will ither have workers' compensation insurance or are sole ensure that all contractors e proprietors with no employees. 5,❑I am a general contractor and l have hired the sub contractors listed uthe I ached sheet. These sub -contractors have employees and have workers' comp. e M We area corporation and its officers have exercised their right of exemption per MGL c. . k rs' comp insurance required.] Type of project (required): 7• [] New construction g. �] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12 [] plumbing repairs or additions 13.0 Roof repairs 14. [J Other e 152, § 1(4), and Nye have no. employees. [No wor e ensation Policy information Any pp the are doing all work and then hire outside contractors must submit a new affidavit indicating such. * applicant that, box #1 must also fill out the section below showing their workers' -comp 1 Homeowners who submit this affidavit indicating y com . bliey number. that check this box must'attached. an additional she ing tworkers'of thpsp contractors and state whether or not those entities have $Contr2ctors, , employees. If the sub -contactors have employees, they must provideemployees.' rn to ees.' Below is the policy and job site I am an employer that is providing workers' compensation insurance for my p y information. f -?A I _ O� I t✓S Insurance Company Name:, Expiration Date: Policy # or Self -ins. Lic. #: City/State/Zip: Job Site Address: a showing the policy number and expiration date). Of the workers' compensation policy declaration Page ( a Pine up to $1,500.00 Attach a copy 25A is a criminal violation punishable by Failure to secure coverage as required under MGL c. 152, § he Office of Investigations of the DIA for insurance imprisonment, as well as civil penalties in the form of � STOP W ORK ORDER and a line of up to $250.0 a and/or one-year imp be forwarded to day against the violator. A copy of this statement may -I rnYYPCt coverage verification. enalties of p j rJ' er u that the information prove .1 do hereby certify under the pains and p , r�a+P a ane 7f: Official use only. Do not write in this area, to be completed by city or town official. • Permit/License # City or Town: circle one): inspector Issuing Authority (• ]Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing p 1. Board of Health 2. Building Dep 6.0 e Phone #: Contact Person: - Information and Instructions 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 oitliire, express or implied, oral or written." An employer is defined as "an individual, ed in partnership, association, corporation or other legal entity, or any two or more of the foregoing engaga 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' compensation affidavit completely, by checking the boxes that apply to Your situation and, if ' necessary, supply sub-'contractor'(s) 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 c p employees, a policy is required. Be advised n I an LLC or LLP does have th t this affid v t may be submitted to the D partme t of Industrial Accidents foi• confirmation of insurance coverage. Also be sure to sign and da be te the affidavit. The affidavit should '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 c self insurance license number on the appropriate line. ompanies should'enter their 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 (if necessary) and under "Job Site Address" the applicant should write "all locations in town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the or 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia w 7356 Date...?// V ......... ,s.e o TOWN OF NORTH ANDOVER - PERMIT FOR GAS INSTALLATION This certifies that .. 11.0. .......................... has permission for gas installation ... (,( F( .................... in the buildings of ........................... at ........... North Andover, Mass. Fee..3� Lic. No.. .... . . AS INSPECTO . Check # 1 k JI - MASSACHUSETTS UNUFORM APPLICATON FOR PERAW TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations /63 3 O _tel I/ I14 20 L t New ❑ Renovation Owner's Name Replacement u Date F-/6•-/6 Permit # 7 3 3 Amount $ 3 d A t cA-4 q(leW.P Plans Submitted ❑ (Print or type)1 U ` Check one: Certificate Installing Company Name 9-0 -►�$ �.Cy►{CPl�lso-i ❑ Corp. Address �� LJg►t/ �%lf� �� : ❑ Partner. ACa/Qr- AfW X3.1 Business- Telephone n 3 3 S % _ 114< ❑ Firm./Co. Name of Licensed Plumber or Gas Fitter/a INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesEr Nor-", If you have checked yes, please in a the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond 0 Owner's Insurance Waiver: I 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 ❑ Agent uoi cuy ccnity treat au or the aemns ana mrormation I nave 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 Massachusetts State Gas Cgde a2d Chapter 142 of the General Laws. By: Title City/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber JaZs:L j -I Gas Fitter License Number ❑ Master journeyman • 3RD. FLOOR '7TH. FLOOR (Print or type)1 U ` Check one: Certificate Installing Company Name 9-0 -►�$ �.Cy►{CPl�lso-i ❑ Corp. Address �� LJg►t/ �%lf� �� : ❑ Partner. ACa/Qr- AfW X3.1 Business- Telephone n 3 3 S % _ 114< ❑ Firm./Co. Name of Licensed Plumber or Gas Fitter/a INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesEr Nor-", If you have checked yes, please in a the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond 0 Owner's Insurance Waiver: I 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 ❑ Agent uoi cuy ccnity treat au or the aemns ana mrormation I nave 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 Massachusetts State Gas Cgde a2d Chapter 142 of the General Laws. By: Title City/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber JaZs:L j -I Gas Fitter License Number ❑ Master journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of, Investigations 600 Washington Street Boston, A LI 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: L-/ A r &t_t ✓ 161 U ?,,1 �` phone #: Are you an employer? Check the appropriate box: 1. ❑ ' I am a employer with 4. ❑ I am a general contractor and I e'nployees (full and/or part-time).* have hired the sub -contractors 2.. I am a sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. (No workers' comp. insurance 5. ❑ We are a corporation and its required.) 1 ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required.] t employees_ [No workers' RA_ c9mp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other t -«« •� � amu- ��t r. nese naso u: , out tae section cetou, sno"v -_g th-;" --11=' comp=aticn polis'y info.�iion. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that isproviding workers' compensation insurance for my employees Below, is the policy and job site information. Insurance Company Name: ff;n r c, , /ry f CU Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: / p 3 .� � ��ly °to City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 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 fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Phone #: /!o — /0 Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Contact Person: I'ermit:/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Information as d Instructions +. 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 employer is defined as "an individual, partnership, association, corporation orother 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 apartrnents and who resides therein, or.the occupant of the dwelling house of another who employs persons to .do maiatemance, 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 licensmg�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 coxnpliance 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' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) and phone number(s) along with their certificates) of Y 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 may be submitted to the Department of -Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the applica ion for the per nit or" license LLs 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 (if necessary) 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 (ire. a dog license or permit to bum 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 and fax number. The Commonwealth of Massachusetts Department of1'ndustrial Accidents Office of Invesfibatoas 600 Washington Street Boston, MA 021.11 Tel. # 617-727-4900.ext41016 or 1-877-MAS.SAFE Revised 5-26-05 Fax # 6.17-727-7749 vv w.mass._gov/dia Date.. e......... !....... . ° TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that �l .............. . has permission for gas installation . . /'-7/ ................. . in the buildings of .. � ",4. .. � :..'. �.'' ................... . at,/ �.�.'.:.�...�, f::.:..f.-:....., North Andover, Mass. Fee? A ..... Lic. No. �' ....�.... .......... :............ . GAS INSPECTOR Check # G^ 35C r,,-) MASSACHUSETTS, UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) ` ��A�, Mass. G .Y 'S Building New ❑ Renovation ❑ Replacement �� Permit # Y-5?- Owner's Named Type of Occupanry Plans Submitted: Yes❑ No p I-V Installing Company Name(,,A Le T A • :lm mA T r)�C, Check one: Certificate Address 3 i? 00 A C H /Y%fa 1%ji-hi . ❑ Corporation �1 r T N U E IJ J1 rl U I ?q Partnership Business Telephone 1,5,)? 2- -11 cl "7 f 2-Firm/Co. Name of Licensed Plumber or Gas l=itter 'jR 0l3 E r- T A • 5 A m (n H 7A en INSURANCE COVERAGE: I have a current ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Ck' No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I 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❑ Agent O 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 the pe ' i ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. By T of License: C� AI�L Plumber n ure of cen u _, or fitter Title Iter er Ucense Number X333 City/Town Journeyman NONE Installing Company Name(,,A Le T A • :lm mA T r)�C, Check one: Certificate Address 3 i? 00 A C H /Y%fa 1%ji-hi . ❑ Corporation �1 r T N U E IJ J1 rl U I ?q Partnership Business Telephone 1,5,)? 2- -11 cl "7 f 2-Firm/Co. Name of Licensed Plumber or Gas l=itter 'jR 0l3 E r- T A • 5 A m (n H 7A en INSURANCE COVERAGE: I have a current ability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Ck' No ❑ If you have checked Yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I 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❑ Agent O 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 the pe ' i ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ner Laws. By T of License: C� AI�L Plumber n ure of cen u _, or fitter Title Iter er Ucense Number X333 City/Town Journeyman Ip I i -Y s 10 r A r O z w O a O � 3 i �1 O O O O s w m i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING'- . (Print r TyP ) 90 % Je` ® Mass. Date 19 Permit Building Location �AncOwner's Namelt&q' #el Type of Occupancy 1i New D Renovation 0 ..T ' ,Replacement Plans Submitted: Yes D Nokelooe - FIXTURES,.. Check one: Certificate Installing Company Name' BENSON PLIMING & HEATIM 00- 0 Corporation Address 17 SFA VIEW AVE. p Partnership WINTHROP, MA. 02152 if Firm/Co. Business Telephone (617)846-7500 Name of Licensed Plumber NLIC HAEL BENSON INSURANCE COVERAGE I have a current liability policy or its substantial equivalent which meets,the requirements of MGL Ch. 142. Yes 9 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ff Other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I 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: . Owner 0 ... .. Agent 0- _ Signature of Owner or Owner's Agent o 1 hereby certify that -all of the details and information 1 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 unopr the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts stat Plum a and C pter 142 of the General Laws. s. Signature of Licensed Plum6er Type of License: Master Journeyman Z License Number 9821 Z z W W Y J¢ W Q O U Z Z O W W W A. x H w 0 Z �: ¢ U¢ Z U. Z a Z W Z a¢ H -j Q W CO uJ W Z Q W E M 3 i- x H a > U Z¢¢ W O O W cn Q W¢ EW- Q 0 W p Q ¢ W J Z M O¢ a O W W o~ W ¢ W= H U a S 3 O a Z= W 3 Y a O a Z Z Z Q w H u- O W¢ X W 3. O= ] f- Z O O W W U 2 ►-+ w a O Y J m W O D J3: S F- W LL 0 5 a Q�'¢ m O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR' 6TH FLOOR __7TH FLOOR - 8TH FLOOR Check one: Certificate Installing Company Name' BENSON PLIMING & HEATIM 00- 0 Corporation Address 17 SFA VIEW AVE. p Partnership WINTHROP, MA. 02152 if Firm/Co. Business Telephone (617)846-7500 Name of Licensed Plumber NLIC HAEL BENSON INSURANCE COVERAGE I have a current liability policy or its substantial equivalent which meets,the requirements of MGL Ch. 142. Yes 9 No 0 If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ff Other type of indemnity 0 Bond 0 OWNER'S INSURANCE WAIVER: I 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: . Owner 0 ... .. Agent 0- _ Signature of Owner or Owner's Agent o 1 hereby certify that -all of the details and information 1 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 unopr the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts stat Plum a and C pter 142 of the General Laws. s. Signature of Licensed Plum6er Type of License: Master Journeyman Z License Number 9821 ` Date ��. 3548 / A ►sr tY NORTiy lb<^°„•,',tioo� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING +•,'�,,r,o SSACHUS� This certifies that nSo se ���.��....................... has permission to perform ....................... . . . a plumbing in the buildings of . C40. q. u.t .t? e ................. at. ,/ 0.3. -0�. J ..V.,. � 44 g r. )k1 ........orth Andover, Mass. Lic. No...�%'?1 .... ''�' PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer