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HomeMy WebLinkAboutMiscellaneous - 1149 OSGOOD STREET 4/30/2018 (2) I- .. . ., 1149 OSGOOD STREET ` 210/035.0-0037-0000.0 f '��_� � J "� Date. . . ... ... . 4 MORTh 3r01`..10 v TOWN OF NORTH ANDOVER r PERMIT FOR GAS INSTALLATION CH This certifies that . . /7. . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of ./ /��!�G�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . , North Andover, Mass. w` Fee. Lic. No.. . J2.Sw . . . . . .�s`�' . . . . . . . . AS INSPECTOR x Check# ^3 1y 5,699 'NLAS,SACHliSETTS U NU ORiM APPUCATON FOR PERTNU TO DO GAS F ITNG (Type or print) Date ( L�—ale NORTH ANDOVER,MASSACHUSETTS T Building Locations 11319, © Permit# S1�SS Amount Owner's Name /�� New Renovation Replacement Plans Submitted •❑ QzQ OW n a x zz z O F xrt x a .za W W F a eF W W rCn 'z d �' x W �. W F Ca F x F z r a � F n O > Gr. F a F rod" Q > C a y e x z O w 3 A C5 a U x > A a F C SUB -BASEMEN T BA SEM ENT 1ST. FLOOR 2N D . F L O O R 3RD. F L O O R f 4T II . F L O O R 5TH . F L O O R 6TH . FLOOR 17T H . FL O OR t S T H . FLOOR -mud (Print or type) Check one: Certificate Installing Company Name Li Corp. Address �ti Partner. S .// ©3a2 Y0 Business Telephone 4 — Firm/Co. Name of Licensed Plumber or Gas Fitter a,Gle INSURANCE COVERAGE Check one: I have a current liability Insurance polic r it's substantial equivalent. Yes 0 No If you have checked�, please in ' ate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 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 1:3 Acrent I hereby certify that all of the details and information I hav _ubmitted ,or entered)in above application are true and accurate to the, best of my knowledge and that all plumbing work and it allation; rforrncd under Permit Issued fort ' a wi I ccmpliance with all pertinent provisions of the Massae uS& atc Ga.' .oc Chap t of neral Laws. By; S LILUau.ire of Licensed Plumber Or Gas Fitter Title Plumber 3!'C1 CityrTown Gas Fitter ice nse Umber L [aster \PPROVED(OFFICE USE GNLY) JOUrneyman t' Date. . . � b. �...... 'c ,aORTh - o? TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION • o� i �,SSACMUSES This certifies that . . . . . . . . . . . . . . . . has permission for gas installation . . G' / .e . . . . . . . . . . . in the buildings of . . . L . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . �G ...F./. . . , North Andover, Mass. Fe 5.00 . Lic. No. /qS � . , .o/ . . . . . . t. . GAS INSPECTOR Check# CX0 .g- 6052 i MASSACHUSETTS UNU ORM APP11CATON FOR PERMIT TO DO GAS FITTING (Type or print) Date Z11 2,A9 NORTH ANDOVER,MASSACHUSETTS Building Locations Permit# Amount$ Owner's Name -7" New Renovation 11 Replacement Plans Submitted D w � U z z d O z $ z V U w x Edy �n 0. z W W d x z z W a W rQzt E" x z z C W d OzC Er m z O Z W 0 F W r z o' 3 a a ° z > a a°. H o SUB-BASEMENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR �"� Check one: Certificate Installing Company Name or typ .- 1�5�� � �C�� El Corp. (� y� Address 1 U 0 11 Partner. Business Telephone ® *� Firm/Co. Name of Licensed Plumber or Gas Fitter �oj), Viq 4,-- INSURANCE INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. YesNoO If you have checked Les,please indicate the type coverage by checking the appropriate box. 13 Liability insurance policy Other type of indemnity D Bond 13 Owner's Insurance Waiv r: 1 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. g Signature of Owner or Owner's Agent Check one: D Owner Agent D 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 or rider Per it Issued for this application will be in compliance with all pertinent provisions of the Massachusett5,,S as C�gde {rid apter 142 of the General Laws. By: Signature of Licensed Plumber Or Ga Witter i TPlu Title tuber City/Town Gas Fitter License Number Master APPROVED(OFFICE USE ONLY) Journeyman Date...... L RTP 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING S CHU ti This certifies that .... ......................................................... has permission to perform ... ............. .............................................. wiring in the building of......75t':-/ . .......... . .............................................. at ...... ........... North Andover,Mass. Fe6 �............. Lic.NW-MO-2....... .......... ............ EucmicALP sPEVR Check # 763 75"1 2 Commonwealth of Massachusetts Otficial Use Only Department of Fire Services Permit No. Occupancy and Fee Checked °d BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 07 1. v7 _ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /14/9 Owner or Tenant --r L V_(2— Telephone No775°'6Y 7 9:9 Owner's Address //�/ Ca,}/�d ars S Is this permit in conjunction with a building permit? Yes ERI"- No ❑ (Check Appropriate Box) Purpose of Building X Gev a RTloR/ Utili Authorization orization No. Existing Service ZOO Amps 2M / /Z11: Volts Overhead Undgrd F_J No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: z Completion of the ollowin table may be waived by the Inspector of Wires. 1 No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot TubsKVA Generators No.of Luminaires Above In- o.o Emergency Lighting Swimming Pool g ❑ rnd. rnd. ❑ Battery Units No.of Receptacle Outlets 1 -3 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 1 y 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[E] Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of Devices or Equivalent No.of No.of Heaters KW 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: E Estimated Value of Electrical Work: ��A® Attach additional detail if desired,or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: C)' Inspections to be requested in accordance with MEC Rule 10,and upon completion. 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 insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove 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 perjury,that the information on this application is true and complete. FIRM NAME: 1—c,)rrt /- c A/ Sr A 44 3 LIC.NO. Licensee: S7gv&,V Go i Signature� -�9- E� Lse-mss'-� LICA6.. /V7,?5_Z- (If applicable, enter "exempt"i the license number line.) Bus.Tel. Address: :;Z v wCx3d M X cJ R. A rM,It,6 u k V�-A 01 i )3 Alt.Tel. *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. 3 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: t ✓ �� 0 7 �� l �. y, �,.� i � ' .� ., The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AL4 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): TU r l .35 ) Address: //® City/State/Zip: Ah /�U2 � Af A Phone.#: 57k �� _ (P 60 Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a generjba tractor and I Type of project(required):. employees(full and/or part- have have hired thcontractors 6. ❑Ne construction 2.❑ I am a sole proprietor or partner_ listed on the ed sheet 7. �odeling ship and have no employees These su sub-contractors ors have g, (]Demolition working for me in an capacity. employees an + Y P ty �P Y e workers [No workers'co insurance 9. Building addition comp. comp.insuran ❑ 3.❑ required] 5. ❑ We are a corpn and its 10.❑Electrical repairs or additions I am a homeowner doing all work officers have isedtheir . .myself.[No workers'comp. right of exemper MGL .❑Plumbing repairs or additions insurance required.]t c. 152,§1(4), e have no 12•❑Roof repairs employees.[Nrkers' 13 ❑Other ------------ mp•insuranuired.] � 'Any applicant that checks box#1 must also fill out the section below showing their workers ec t Homeowners who submit this affidavit indicating they are doing all work and then hire outside c�tra tors must submit tion Policy 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 an employer that is providing workers'conepensatton tnforn�atton. insurance for my employees. Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.M 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 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 maybe forwarded to the Office of Investigations of the DIA for insuran a covers a verification Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si tore: Date: Phone#: 7Person: nly. Do not write in th area,to be completed y city or town 0 claL [Contact Town: Permlt/License# ority(circle one): ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector on• Phone#: Date.17/1. t. . �..�f! < -- .. .. .. .. . ., MORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .�__, � 3�°ate nn•�o•gh W 9SSACMUSEt ' This certifies that . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . in the buildings of . y. . . . . . . . . . . . . . . . . . . . . . . . . . at � . . . . . . . . . . . North An�over, Mass. Fe . . . . . Lic. No. GAS INSPECTOR Check 4,5�f 6061 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) r , Mass. Date 2f�f 2007 Permit ,-9'j- Building Location f Owners Name Type of Occupancy_ New Renovation❑ Replacement❑ Plans Submitted: Yes❑ No❑ LLI I i O m O � OaO a 0w Z � �w JW � W � � >z0o= a � � L 0. SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 4111 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name � (� Check one: Certificate Address /��ti,� �_ r\ ,. - /(h �� ❑ Corporation axxaBusiness Telephone_ ?R,3-6 9"Or ❑ Partnership Name of Licensed Plumber or Gas Fitter E ' 'moo' INSURANCE COVERAGE: I have a curren bll)ty Insurance policy or its substantial equivalent; which meets the req Yes NO uirement; of MCL Ch 142. p If you have Checked yes,please indicate the type of coverage by checking the appropriate box. A liability Insurance policy g,,"' Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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 sperm appilcation waives this requirement signature of Owner or Owners Agent Check one: Owner ❑ Agent ❑ I hereby certify that all of the details and Information I have submitted for entered)in ab ov ation are true and accurate to the best of my knowledge and that all plumbing work and installations performed under.the per ued for is application will be In compliance with all pertinent provlslotts of the Massachusetts State Gas Code and Chapter 142 of the eral Laws 13 Type_of License: By umber a re ofL tensed lumber orCas Fitter Tide ❑Gas fitter �lryrlown &A1 ster License Number APPROVED(OFFICE USE ONLY) ❑journeyman Date. . . . ... . "ORT" �� TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ,SSACMUSES This certifies that . .�f. . . . . . . . . . 5-r _`>Ps2 . . . . . . . . . . . . . . . . . . has permission to perform . . . . . 1.1/. . . . . . . . . . . . . . . . plumbing in the buildings of . . .7 ,l�P-!l . . f� . . . . . . . . . . . . . . . . . . . at ... .7 . . . . .CJ 55.cxy 1.,.�J. . . . . . . . . . . . ,, North Andover, Mass. Feet;7!:S-4. . .Lic. No. -,?- U0.t . . .;/` . .1e-l*. . . . . . . . . . . . . . PLUMBING INSPECTOR Check #��- 7438 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ...`— Date !�//L�O. 7 , Building Location / °y LQ GJ Owners Name /y�( /'� Permit# Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes No FIXTURES E~ rn R4S& M lSi HOM 2 ZNl F><DQt 3MHfm 4M HBM sIf EBM 7MHfM 9M Rf at (Print or type) —� Check one: Certificate Installing Company Name VA�I a / c �f�h Corp. AddressSIP �G 4 Partner.' Business Telephone,"' El Firm/Co. Name of Licensed Plumber. =osly y 0A. / 'l r�C/•, Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 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 i ignature Owner Agent 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 ins tions nrr der Permit Issued for this application will be in compliance with all pertinent provisions of the v S e and Chapter 142 of the General Laws. r BY o ns er Type of Plumbing License i Title City/Town i 2©u�m oer � Master Journeyman APPROVED(OFFICE USE ONLY r Date....�...3.l."":D!b... I 0e NORTF�,� 3: TOWN OF NORTH ANDOVER p PERMIT FOR WIRING r4 ,SSAC14USE� Thiscertifies that ........... ....................... .................... .................................. 'L has permission to perform �G e wiring in the building of................. � ........................................ at........ .1.y ...©> ��? ......... nnT............... .North Andover,Mass. Fee..�°.�..... Lic.No.a�..5Pr�..`,i3 ..�"......... . ...... .(' ELECTRICAL INSPECTOR Check # ✓ �� +�// ' 6898 Permit No. Department of Dire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: P7 - 3 I l- Z;) 4-1 City or Town of: To the Inspector of)`Vires: By this application the undersigned jive's notice of his or her intention o perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a buil ing permit? Yes F] No (Check Appropriate Box) Purpose of Building /lpt:Ze ylwe.it i Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps ! Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of proposed Electrical Work: n"1-mq r) e(�1 I Completion of the ollowin cable may be waived by the In ector 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 Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. BatteEy Units No. of Receptacle Outlets 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.No.of Air Cond. Tons No.of Alerting Devices No. of Waste Disposers Heat Pump N_umber Tons s_ KW No.of elf-Contained p Totals: _ _ _ Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW ecuriho o systems:- s or Equivalent No.of Water No.of No. of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No.of Devices or Equivalent OTHER: i 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. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE UK BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury,that the information on this application is true and cornpleta t�, FIRM NAME: "z I' ���.�/j� © L C� '1 i 0 led io' J 6i �i LIC.NO.: 119 7 4 7 Licensee: , ,, M; 4-- �i U Signature �� i ( ,,�,�� LIC.NO.: _ I a Itcable,enter "exempt"in the license number line. (f pP � ) / Bus.Te/1��:'- G ��ls�°'�� Address: Z ` Alt.Tel.No.: *Security System Contractor License required for 6s work;if applicable,enter the Iicense nhimber here: 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 agent. Owner/AgentPERMIT FEE: $ Signature Telephone No. I N2 Date... ..... '`s f�9 N- 1669 �aORTI� °ft"'°:•�"� TOWN OF NORTH ANDOVER F ~ aim-oft.. PERMIT FOR WIRING ��ssHCHU This certifies that , . "``. s -...... -� has permissiono perform,.,?:'.: ......................... wiring in the building of�r ......... .................................................... at Z�`�.1.. r'�1.. � '.....�.:.?................. .North Andover,Mass. 0 w.v nn UELECTRICAL INspwr R 05/27/99 11:34 50.00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer U) h,i (Errr Iir[ujzzzz II u�srar OR"Ce Use Only r Deparment of Public Safe:y P!rrr:ir-vo. BOARD OF FIRE PREVENTION REGULATIONS 527 Ct\1R 12:00 Cccupancy S Fe- Cneued �o 3M (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK A!1 work to be perorrn d in accordante with tre Ntassachusets ciec•ical Code.527 OoR 12:00 ' Q (PLEASE PRINT IN INK OR TYPE ALL LdFOZ. AA-`, Date A"" City or Town of NOOF NMI oy fn 'To the Inspector of Wires: The undersigned applies for a permit to perform the ele ric_l work desc-i ea below. Location (Street S Number) �r�r Tenant ��6�0_&L:1+ `��2 �/�'—����So :. O Owner's Address Is this.permit in conjunction :tirh a building permir. Yes -41%40 I (Check Appropriate Box) Puroose of Building Utiiici Authorization Existing Service Amps r Voits Overhead IJ Undgrd a -No.of.deters P New Service Dm -Nmps�rt7.,d Voits Overhead I� ( ndgrd t .- No. of%ne ers - 1 - �:` ,dumber of Feeders and Ampaciry Location and Nature of Proou,?d Elect.-:ral Work " TOTAL ,Na. of Liehrine Outlets ( Nn.of Hor Tuns I No. of Transrorrr"ers KVA < ♦oove Nn. of li4ntin¢ Fixture, I Swit'trirs Pool stmd. is emd. (!1 Cenerators KVA No.or E.^t rerge cv Lignnng No.of Recemac!e Oudem ' I No.of Oil Burners I BaeryUnits " No.of Switch Oudets I No.of Gas Burners F;RE ALARMS No, of Zones �otai No. of Detection and No.of Ran¢es I Nn.of alt Conditions-, Ton, Initiating Oevices . Heat T o(.a ,orae No.-ci Sounding Devices No.of Discosais I No.of Pumoa Toni KW No. of 5eif Contained f No. of Oisbwasiers I SoaceA-krsa Heatins K';%/ m %r Cetraonr<ounici oeviees �sunic:tai �No.of Orvers I H.eatina Devices K',v I Lopla, Connection l_.lOther r No.or . No. oraLow vo�tge No. of Water Hearers KA Si¢ns Ballasts whine" No. Hvdro Niassace Tubs I No,of Motors Total HP I OTHER pp , INSURANCE COVE.¢ACE: Pursuant to the requirements of Mafsachusras General Laws I have a current Liabi(ir/Ins�ur,ar Policy including Coma(emd,,Operations Coverage or its substantial equivalent.M'INO=!have submitted valid proof of same to this oft-ice. YES V,-"O if you have ched< ES.please indicate the type of coverage by checking the appropriate box. - INSURANCE LLl BONG II OTHERO (P!ease Specty) (Expiration Date) Estimated Value of Electrical Work S Work to Start ' /� Inspection Date Requested: Rough Final Signed under the penalties of perjury: FIRM NAPA E Atk LIC. NO.rT?19 33 Licensee —1' ® g OK (917 (se Signature t1AUC NO.O���O Address FES 9LkRrbi 4 " 0A13 Bus. Tel. No.�2o'��aB—ZT— OWNER'S INSURANCE WAIVER.I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as required by Massachusetts .Ceneral Laws, and that my signature on this permit application waives this requirement Owner Agent (Please check one) Telephone No (Signature of Owner or Agent] Date. . /.f .1.� "O°T:�� TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ,'rSACHUS� This certifies that - / . . . /. w . . . . . . . . . . has permission to perf cmL. . . . . . . plumbing in the: uildings of %�✓ . .. . . . . . . . . . . . . . . . . . . . . . . . . . ., North Andover, Mass. at . . . lr. . . . Fee.tt!.•.�P.Lic. No.. . �7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR • Check # � 6128 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS s� ��// / r Date (l Building Location %{ Y Q 5 5 O�rJ Ownes Name l�� f' Permit# Amount T`pe of 4ccu anc New Renovation Replace ent Plans Submitted Yes No ❑ 1 IXTURES S ew e rr T-e v r Cf CA Ste» R4S VIIVr 1ST ILOOR �>HI� �FIOCi2 4II3I�IOC[t SIH)HIOCIt 6M HDM 7M FLOCIt S1HMOM (Print or type) �j /� Check one: Certificate Installing Company Name / c✓JC L) �7` (T i �- R—Corp. Address ��� �—� S Partner. 7usmess Te ep oneS d _ c� Firm/Co. Name of Licensed Plumber: TL/JC 6 Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 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 ignature Owner F Agent 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 Massachusett late01 mbi a and Chapter 142 of the General Laws. By: Signa ure icense u er Ty f lumbing License `. Title City/Town dense um er Master Journeyman ❑ APPROVED(OFFICE USE ONLY