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HomeMy WebLinkAboutMiscellaneous - 11 SPRUCE STREET 4/30/2018 11 SPR A056 0000.0 � 2101045 L Date.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHU This certifies that....mi\........... ................................................. has permission to perform......1. 17............................................................................. plumbing in the buildings of......111.\-q......... ...... atm....... ... . ................................ No ove Mass. Fee.,?A.Q.�......Lic. No. U.GO..... ................ ... . ..... .... .... ...... .... .................. U u�.� t��P�0.. MBIING�=INSPECTO Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY -- _ _ __. I MA DATE[ _�- /S' i PERMIT#'J 11 _. __ _ JOBSITE ADDRESS LI_. . p, UC t— rszt f . _______._ OWNER'S NAME �a POWNER ADDRESS 1_11,---- P_K_L C—C.._5 TELL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL.N PRINT CLEARLY NEW.Q RENOVATION: REPLACEMENT:Ej PLANS SUBMITTED: YES NOR NOR FIXTURES Z FLOOR-; BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB —. CROSS CONNECTION DEVICE I ___,._i DEDICATED SPECIAL WASTE SYSTEM 1 .__ I —__ __._.._ _! _.—_ ___ I ._— I _ _ DEDICATED GASIOIUSANDSYSTEM I ___ # _____ _ _1 i __—! ______• DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ __ __ _—` — __I J — DEDICATED WATER RECYCLE SYSTEM DISHWASHER _____-J _-- _J _-- -__ _ ._._._._ DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR .___--' -__-__3 -___-- — —: _ ___ _._... KITCHEN SINK .......-1 —_.—I __-- LAVATORY _.... ! -- -- - - --- ROOF DRAIN ......—.1 ___j ____J _ --- _...__. __ __ — ► ._—__# ...-._.�i .—_1 --- ---J ' SHOWER STALL SERVICE/MOP SINK \T01LET _. i —_ I ---J ._..._-I ^J URINAL ----! - ----- -—' --- --- _. _—. — _ -! — . _ ,. w WASHING MACHINE CONNECTION WATER HEATER ALL TYPES —�J J WATER PIPING OTHER _._i j I INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES( NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY- OTHER TYPE OF INDEMNITY Ej BOND 0 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 �.�`�. AGENT [] SIGNATURE OF OWNER OR AGENT I hereby certify that ail of the details and information l 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 ail Pe nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /� L. 4a&R) PLUMBER'S NAME 1WK--.A.. '.,. _.. ._... ._(LICENSE# _...II to(, SGc SIGNATURE MP 59 JP __i CORPORATION #=PARTNERSHIP E3# .._........_..__'LLC[.I# \COMPANY NAME .MQ,i). �u�wwbUiJ4_ '(� ADDRESS CITYI 4v_Vm I t_�_ ------- -..-- ------ STATE - Mw--- ZIP X133 TEL FAX �� CELL 1£3-771-�Y�l EMAIL _cn_ — r _L'o i��� -----_ -- -- r• • The Commonwealth of Massachusetts Department of Industrial Accidents >; I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Annlicant Information Please Print Legibly Name (Business/Organization/Individual):M.A. j'. —P,-,A t%13 I.--I r c4 6A r lg3a Co. MAR_W_ �� 6AC,,j, Address: Lf6 LoCKE ST. (A01'r Z33 City/State/Zip: N ROQW1LL i MA O 1 Phone#: 91 L'T-7 7/-6 I/ / Are you an employer?Check the appropriate box: Type Of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.Ug I am a sole proprietor or partnership and have no employees working for me in 8. E]Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.F1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10[(Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.N Plumbing repairs or additions 5.a I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.0 We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are 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 subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. Ian:an employer t/rat isproviding tvoi/cers'compensation itisurmtce for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy#or Self-ins.Lie.M Expiration Date: i Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerci y undef the pains and penalties of�that the information provided above is true and correct. Signature: b Date: . qql (OST o?y t a a Phone#: 9 7 6^ -7 7 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#: r' < OMMONWE LTH OF MIASSAmb TT. S. .- -7777=... BOAR D:'Ol~ PLUMBSRS```AMD GASF.11 ERS; SSL[I S.THE FOLL0 4: L I CENS£ ', �W SED AS::;;A=> TEVPLUMBE' ' $ : (�.: *u 40 LOCKET - W `> `VEa`H I LL > ><_ << is 01830-55:14.,... • 32AAR t Date..q.. .;-,g...-1.y... 10771 cF�aOpTH,�O TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING U gB�cHUss t .This certifies that . ....n.�^'"-. ..... \ ...............:........................... has permission to perform....E"a."r-.^......V.... -� °'4''� . .................. .................................... plumbing in the buildings of.... ..?. ..... S . ............................. ....................... at.......1.\..... .f.�`, ....................................... ., ....... . North Andover, Mass. . Fee�{ s ..Lic. No. 13�. S... ...................4 ................. -PLUMBING INSPECTOR Check# 602 7 1aN_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY North Andover MA DATE 9/29/14 PERMIT# ` mi JOBSITE ADDRESS 11 Spruce St. OWNER'S NAME Belford Construction POWNER ADDRESS 130 Marbleridge Rd, N.Andover MA 01845 TEL 508-509-9430 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ZI PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 1 Wl I NAL WANAL MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSUR NCE AIVE : lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachus e d that y signature on this permit application waives this requirement. SIGN 0 0 N R 0 AGENT CHECK ONE ONLY: OWNER F1 AGENT ❑ I hereby certify that al the details and in ormation 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'S NAME Robert J. Frazier LICENSE#13425 SIGNATURE MP® JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Bomar Plumbing &Heating ADDRESS PO Box 694 CITY Derry STATE NH ZIP 03038 TEL 603-325-8958 FAX CELL EMAIL Bob@BomarPH.com The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations r _ _ 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Bomar Plumbing & Heating Address: PO Box 694 City/State/Zip: Derry, NH 03038 Phone #: 603-325-8958 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2. X am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑X Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152,§1(4),and we have no 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. I 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 state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Fire Insurance Company Policy#or Self-ins.Lic.#: WC2-31 S366059-022 Expiration Date: 22-Apr-15 Job Site Address: 11 Spruce St. City/State/Zip: N Andover MA 01845 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u e the ins nd pe alties of perjury that the information provided above is true and correct Simature: Date: 9/29/14 Phone#: 603-325-895 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: o _ ONWEALTH OF MAiHUSETfS::; a ' e e ® . . • • PLUMBERS'---A I17 G A S Fl T S:S.0 ,$ex THE F 0 L �`�.;.,:: LOWIf`G'`'fi I CENSE,`-' `L[C15E0 A$ A AS ER PLUMBER tE B RT J FRAZJ ER. C PO BOX'b9t ba . CRY 0 - 3038 o694J_ �7141� COMMO ' e NWE ITH OFT • Will. . • MA: 1 CHtlSE�S; . 11111 No PLUMBR '' IVO 1S.SU GA,SF.I.Tr > ES:.::THE FOLLOW, RS L E S L I CENSE A . 0l1#;N :yMAN PLUMB , R013€RT J FRAZ IR PO BQ 9*4bt `. PRY' €;IVH 03038 -0694 tDate.............v..... ..................... 4 OF 4ORr#1 TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING CHU5�t This certifies that I...!...!..1. . 1..................�..... ........!e......I........(.�...... .............................. has permission to perform .........V. ±. .....(� rrto�...e............................... .............. wiring in the b ilding of........ ....'� ...................................................................................... at ......1..1.......... I....'Q t.1.t-L.........Y... ...................................-N rthn Andover,Mass. Fee..............................Lic.No. ................. ..............................!...... .. ........ ...................... d ELECTRICAL INSPECTOR ✓ Check# l.9 s I t V Z _ - - commonwealth of Massachusettts Official Use Only QU Department of Fire Services Permit No. Occupancy and Fee Chec ed BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ,527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: L I9� City or Town of. NORTH ANDOVER To the In pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant ; 2 i,/— Telephone No. Owner's Address Is this permit in conjunction with a buildinpermit? Yes No ❑ (Check Appropriate Box) Purpose of Building 51 ilbi M/ Utility thorization No. Existing Service /V) Amps / Volts Overhead UUndgrd❑ No.of Meters New Service /0 Amps / Volts Overhead[�J/ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: i , et=50t, Completion o the oll in table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of LuminairesSwimming Pool Above ❑ In- El --o mergency ig mg rnd. rnd. Batter Units 1 No.of Receptacle OutletsS No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW.....••.•. No.of Self-Contained Totals: �•••' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KWSecurity System .*- No. No.of Devices or E uivalent No.of WaterNo.KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. of INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless f� the licensee provides proof of liability in .rance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of erjulry,that the information on this application is true and coriptete. FIRM NAME: �. LIC.NO.: Licensee: Signature If LIC.NO.: 65 ,G ffappltcable,enter`exempt"in the licenseber line.) Bus.Tel.No.! Address: nae M Alt.Tel.No.: 5 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE.$ 1 t d9 � ti _. ELECTza][CAL PERMT NO. - ELECT'MCALI SFECTOR-... r Z�l TION.- p+ailed--[ I 72eiuspectionrequire(l($50.00)•-[ I s: - _ t t •s•• t S. (Xnspeefioxs' ignafoxe x oiiiiaYs) pate 2.FMtRl..1)Ns. Xc o e ' Passed—[ ] Failed—[ ] R184nspeetionzequired($50.00)--[ f InspectorsComments: (Crisp ctors'Signature-• initi Date 3.TMER GRODM MSTFICITON: Passed- [ 1 Failecl—[ I Re-inspection required($50.00) Inspectors'cw3 m.ents: (Inspectors'$ignatuz•e•-no initials) Date !' • x 4.INSPECTION—SETca'VICE: D'A k L CAL N_Q NAT ONA GDi i Passed--[ I Sailed- [ Re-inspecfionrequired($50.90)••[ I Inspeetbrs'comm.eAis: (Inspectors'$ign�ture••1io initials) Date Eed ovimenfs: ` (&spOdors,Eignatuxe no initials) Date DOOM.TAGS.APX TO BE FILLED ODTAND LEFT ON SITE IF THE APXA.TO BE INSPECTED JB.WOT ACCESSIBLE AND A.BE wsPECTZm OF_$50.0 0 M TO BE CHARGED. - The commonwealth of#Massachusetts - - - Department of Industrigl Accidents Office of Invesfigations 600 Washington.Sheet Boston,MA 02111 www mass gov/cira ' Workers' Compensation Insurance Affidavit: Suffders/Contrractors/EXePleasectlic ����umb r .A,-pppcan Information Name(Business/0rganizationitndividud)' Address: Ciiy/State/Zip: Phan#: Are you an employer?Check the appropriate box: Type orproject(required): 1.❑ I am a employer with q. ❑ I am a general contractor and I 6. El New construction ees p Y ( part-time).*em to full and/or have hired the sub-contractors listed on the attached sheet.T 7, [(Remodeling 2111 am a solepropxietor orpartner These sub-contractors have 8. []Demolition ship and'have no employees workers'com .insurance. ' working forme in any capacity. p 9. ❑Building addition [No workers' comp.Xnsurance 5. ❑ fi area havcore exercised and its 10.[]Electrical repairs or additions required.] officers have exexcisedtheix ht of exemption per MGL 11.[]Plumbing.rep airs or additions 3,Elrz X am a homeowner doing all work c�52,§1(4),and we have no 12.Q go of repairs myself.[No workers comp. employees. o workers' insurancerequired.]i13.❑Other comp.insurance required.] ,Any applicant that checks box#1 must also fill outthe section below showing their wbrkers'compensation policy information. -Homeowners who submit this affidavit indicating they ere doing all wont and then hire outside contractors must submit anew affidavit indicating such. Tcontractors that cheAthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that isproviding workers,compensation insurance for my enployees Below is the,polley and joh site information. Insurance Company Name:. Policy#or Self-ins.Lic.#l: Expiration Date: Job Site Address: 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 xequiredunder 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 WORD 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-o£ Investigations of the DIA.for insurance coverage verification. I do Hereby cer'to under the pains and penalties ofperjury that the information provided above is true and correct. Si ature• Date• Phone#: Official ,se only. Do not write in this area,to he Completed by City or town offzcia.. Cite 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 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 ofhire,- express or implied,oral or.written." An employer 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 lobal licensing agency shalt 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 ofpublic 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 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,apolicy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confnmation of insurance coverage. Also be sure to sign and date the affidavit. 'he 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 Offfeials Please be sure that the affidavit is complete and printed legibly. The Departmenthas 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 afff davit 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 ox 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 thanlc 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 anal fax number: Tho Commonwealth OfV-0ssachm"At—q Depaftmt df dwWal Aceldenta 6.Q()Wa &:a ftod Bwton,MA.02111 TQJ,#617-7-27_4900 at 406 o-x-8,77-VASSRAFF, Revised 5-26-05 FaX#617-727-7749 �.tua�s,g4v�cl�a. eac a — I i t .COMMONWEALTH OF MASSAHl1SETTS BQAR.F]of LECTR ICIA.N.S i ISSUES THE FOLLONG LICENSE WI AS A REG JOURNEY,MAN <ELEC�TR>I C[,A fu` THOMAS P .DQHERTY 1v. j 3 WOLCOTT R0 4. ` 3z wORURN MA 0180t 2 28go8 E 0'7/31/<16 3 12697 Y ' �� 7466 Date../yo;,R//11)...... • r f ,,ORTN � Z. TOWN OF NOf TH ANDOVER • PERMIT F GAS INSTALLATION • a . y S'4 USEt� This certifies that . IAw. , f . . . . 4,l(� . . . , has permission for gas installation . .Sol' fit. . . . . . . . . . . . . . . . in the buildings of . . . . Q_. !l�. .% 6 .0. . . . . . . . . . . . . . . . . . . . . . at j/ S�f l.1 . . . . . . . . . . .. North Andover, / Mass. F hjf 70 /J ;1 �GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING .U'r City/Town:9 MA. Date: / Permit# l Jke-'Building Location: Owners Name: 21) /e-0 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residentiaix New: ❑ Alteration: ❑ Renovation: ❑ ReplacementK Plans Submitted: Yes❑ No FIXTURES vi W W Y F to ~ 2 W W < m = 0 W w v (n ~ to p w LU z z o w R O Nw w Lu to OF Q a H D w X w � W a W W w z 9a rn = w � W z w M W V W z 0 J F- H O z J U' LL N = W F- W W z W >- W U) J Q Q m W O z O w H H v o o _ = g o o°. g 0 > > > 3 0 SUB BSMT. BASEMENT 1 FLOOR 2 ND FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate# Installing Company Name: e 4 M Corporation Address: City/Town: State: ❑ Partnership BusinessTel: la�9-f o?a Fax: 9a0(o ❑Firm/Company Name of Licensed Plumber/Gas Fitter: e INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Dw/,- 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box❑;I 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 Gen Laws. Type of License: CBy Plumber 1 Title Gas Fitter Master Signature n ed f Li PI ber Gas Fitte City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY ❑ LP Installer FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH PLUMBER GASFITTER.LP INSTALLER LICENSE NUMBER: PERMIT GRANTED❑ DATE: GAS FITTING INSPECTIOR f `J 4 Date�U��W yo MORTM •'40 TOWN OF NORTH ANDOVER �+ c ' PERMIT FOR PLUMBIN SACHUS This certifies that . . ./. ! , h^ ,�. . . .Uh-t . . 61'l has permission to perform . . . . . . . . . . . . . . . . . plumbing in the buildings of . . f. Cd. . . . . . . . . . . . . . . . . . at , .�� . . . .5�✓(1��.. . . . . .-�. . . . . . . . North Andover Mass. Fee 6.51.1(kLie. No.3�R(O. . . . . . .�.'� . . . PLUMBING INSPECTOR Check !t f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING aNCity/Town: MA. Date: / / P rmit# Building Location: Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:❑ Renovation:❑ Replacement: Plans Submitted: Yes❑ No FIXTURES DEDICATED Z SYSTEMS LU z W Y z Lno 0 WZ > u H W OQC Z LA Z a w Z a[ 2 of Z Q Q vWi Z_ ) N vQi w F Q ?� m N cc F x in 0 _j a X = Q Q C OJ = Q W 0 Q Z W 0 W Z W Z U d U. W 3 w u H Uj in CL 0 of 0 3 Hg g °> > 0 0 0 Z Z Q Q Q =L61,_ owRwww O W Q Q a m Co 'o o z x o: 3 3 3 0 a 3 SUB BSMT. BASEMENT 15T FLOOR 2 °FLOOR 3 °FLOOR 4T"FLOOR 5T"FLOOR 5"FLOOR /r FLOOR 8T"FLOOR Check One Only Certificate# Installing Comp ny Name: A �v Corporation Address:i� !� City/Town:/v Stater �, ��}} s, //�� ` ps/ta� ❑ Partnership Business Tel:` z3 k_&:' 2Y Fax: 924?- s©7-( r ❑Firm/Company Name of Licensed Plumber: '51 9 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yesk No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy X 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)rega g this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit' s ed for this appiica ion will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 o General Laws. By Type of License: ~ Si atu a icense lumber itle lumber i7 C aster License Number: /(�� APPROVED OFFICE USE ONLY ❑Journeyman FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS) FEE: $ PERMIT# APPLICATION FOR PERMIT TO DO GAS FITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING SKETCH PLUMBER,GASFITTER,LP INSTALLER LICENSE NUMBER: PERMIT GRANTED❑ DATE: GAS FITTING INSPECTIOR ` Date. ... .. ... NORTH Of ,.ao ,,1ti0 TOWN OF NO H A OVER PERMIT FOR GAS I TALLATION p9 h SSACHU5ESl This certifies that . . . . . . ._r f`.�!ft?,/�t. . •f A/ . . . . . . . . . has permission for gas installation . is y p��.� . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . .�fG��. . . �1. . . . . . . . . ., North Andover, Mass. Fee. . . �/ . . Lic. No. �. . �h!l /�r�1. . .`. . . . . . . . GAS INSPECTOR Check# JJ5%) MASSACHUSETTS UNIFORM APPLICATON FOR PERNK TO DO GAS FMTr G (Type or print) Date ']lie/U 6 NORTH ANDOVER,MASSACHUSETTS Building Locations L) r- ca Permit# Amount$ Owner's Name 1 Ay/—e v New❑ Renovation Replacement 13— Plans Submitted U 94 x w � � rn WF G zn a z z x C4 a W WW z 0 H w F U a H x O x w 5 A C7 O OV C4 A o0. F O SUB -BASEM ENT B A S E M E N T r 1ST. FLOOR 2ND . F L O O R 1 3RD. FLOOR y 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 18TH . F L O O R (Print or type) Z Check one: Certificate Installing Company Name __ 1 l ,PGfiL-G� /�p� �� Corp. � �� Address -� Partner. Business Telephone Firm/Co. Name of Licensed Plumber or Gas Fitter "--_- INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes O.i No❑ If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy 01�' Other type of indemnity 13 Bond 13 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 13 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 inst ations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa c se s Stat as Codd Chapte 42 of t General Laws. BY: Signature of Lice sed Plumber Or Ga iter Title ©'Plumber City/Town 13 Gas Fitter icense Numner 71-master APPROVED(OFFICE Use ONLY) Journeyman