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HomeMy WebLinkAboutMiscellaneous - 117 MILLPOND 4/30/2018 117 MILLPOND 210/095.A-0117-0000.0 - -- i `� Date......1.1.2*.... * TOWN OF NORTH ANDOVER PERMIT FOR WIRING CHU This certifies that ............................................................. has permission to perform 0 JJ ..............................................j(r.......................................... wiringin the building of........ ... .'�........................................................ ...... ..... ...... at .......IS ....... L..........................................I No Andover,Vass. Fee ..........Lic.No.`�'.Tft I - 0 ELECTRICAL INSPECTOR Check# I! - - Official use only Commonwealth of Massachusetts Department of Fire Services Permit No. 1 Occupancy.and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank 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: ioLi L elI(— 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) L 6- r� Owner or Tenant /1--/l %C{Al —I Telephone No. Owner's Address S 7 --1. 'If Is this permit in conjunction with a building permit? 'Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building ,&IFS 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: Completion of thefollowing table may be waived by the Inspector o 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. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMSNo.of Zones No. - N .of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges �. No.of Air Cond. TotalTons No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: """"''.""'..........."""""'I"""""""""""" Detection/Alerting Devices No.of Dishwashers /` Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent Heaters No.of Water KW No.of BalNo.as Ballasts Data Wiring: �T Si ns No.of Devices or Equivalent �l No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications No. f Devices or E uivalent i 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: l�—l — 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 P BOND ❑ OTHER ❑ (Specify:) Icertify,under thepains andpenalties ofperjury,that the information on this application is true and complete. p FIRM NAME: c/ /Co r/4c/ LIC.NO.: 2 �/ ) Licensee:G 1-c-f /20 yl ej- Signature,—Q-,----- LIC.NO.: (Ifapplicable,enter"exempt"in the license number line.) Bus.Tel.No.• Address: & z- I l c 47 —T 1,U G/po Alt.Tel.No.: V(r— *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. �� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normall required by law. By my signature below,I hereby waive this requirement. I am the(check one El owner ❑owner's agent. Owner/Agent . _ - PERMIT FEE:$ Si ature = Telephone No. _ ELECTRICAL rnjWT NO. )WSPECTXONREPORT.. BLE CMC-AL MWP- TOR.-•- _ • R P -:-:1i] assed--[ ] Failed--[ ] Re-:inspection requi�re�f( 50.OD)-•[ j inspectors'co7oa�me�afs: - QGau pectoxs'Signature-no iP-! ls) Date Z.J�J(NALXNS CTION, Passed•-- Failed—[ ] steinspectioareq ired($50.00)--[ Inspectors'comments: (Easpectors'Signature•-no initials) Date 9-1( -,13 / 3.UNDER ORODM INSPECTION: Passed—[ ] Failed-[ ) Reinspection required($50.00)••[ Xnspectors'ma m.ents: (inspectors'Signature-no initials) Date �'.I1�TSl'ECTION—SEItY.�CE: � - DI t+l CALM,D NATIONAL GMID: N'AVI M.-. Passed—[ ) Failed—[ ] Reinspection required($50.00)••[ ] Xnspectbrs'commenfs: (luspectors'Signature••;Pio initials) Date • F' r � I 5.MBPECTION-OTHER:' Passed—[ ) )Palled--[ ] Reinspection required($50.0D)•-[ j Inspectors'conim.ents: �uspectorsl Sjinatuxe•-no ii Faals) Date D 0 O TAGS ARE TO BE TILLED OUT AND LEFT ON SJITE IF THE AREA TO 33B INSPECTED JB TOT ACCESSIBLE AND ARE JW'SPECTION OF A50.0 0 IS TO BE CHARGED. The Commonwealth of Massachusetts F Department of Industrial Accidents d 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia b�•v Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. Please Print Leeibly Applicant Information Name (Business/OrganizatiorAndividual): v t � /CU l ACUy.6 e- f Address: / %%G C lf� City/State/Zip: ;' 9���w7 �� Phone#: Z' Are you an employer?Check the appropriate box: Type Of project(required): LFJ I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.DdI am a sole proprietor or partnership and have no employees working for mein 8. F1 Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.Q 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 11.[]Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole proprietors with no employees. 12. Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.❑We are a corporation and its officers have exercised their right of'exemption per MGL c. 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. $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. an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site lam information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: — Ila, Job Site Address: �� lel i G G �G wl) City/State/Zip:�/ Gf2T/f 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Date Signature: / I Phone# —� r Officialonly. Do not write in this area,to be completed by city or town official. n• Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son• 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 of hire, 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 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 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 Departmenf 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 application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(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 (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 www.mass.gov/dia s Divisi! n of Professional Licensure:License Search http://license.reg state.rm.us/pubLic/pubLicenseQ.asp?board code... . The Official Website-of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.GovHome State Agencies A-Z Topics Home)Division of Professional Licensure> ONLINE SERVICES Check a License ;—y a P' ,CO. i/' ##.. i 3 �.. .,., � .,� .+� �'�L(.',�+���.s.�a�� �.,fIC�.1-1E'. Locate a Licensed professional By the Online Address Change Contact the Agency LICENSEE Name:LOUIS KOUTROUBIS REFERENCES& NAHANT,MA RELATED INFO NEW SEARCH Licensing Board: License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS:E License Number: 27938 Status: Expiration Dat : 7/31/2016 Issue Date: 3/26/1984 Exam Date: 2/4/1984 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday,May 18,2015 at 8:16:52 PM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us 1 of 1 5/18/2015 8:17 PM Dated �.�.:11)........ 11288 i TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING CHUS�s This certifies that......K.. ...................... o �i has permission to perform.... W....... .!h.. ..h !.!. . ! ................ i gs o .......... ...... ft?..'....................................... plumbing in the build !J at... b.1................ .`.`............... North Andover, Mass.' . Feel( .�50....Lic. No.2 3�1... ................................................................................. PLUMBING INSPECTOR Check# e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK !� CITY /'�, i M DATE ( PERMIT# i JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT: �' PLANS SUBMITTED: YES® N0�1 FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB ! ! ! ! ___... _ ! .._— f ! __._.. _ .!' __._..! _! CROSS CONNECTION DEVICE _! _ ! _ _ _ __. ! _ ! _ _. ....,_ _! ._..__.; _.. _ ` ! 1 DEDICATED SPECIAL WASTE SYSTEM ! __..,.._l I I ! T _ _. l _! 1 I I f. _I DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM _..fi i DEDICATED GRAY WATER SYSTEM I ( FE-77-D __._.I ---jl===== I DEDICATED WATER RECYCLE SYSTEM -..__ DISHWASHER DRINKING FOUNTAIN _I ..___...-! _____ _________f ____! -- ! --__._I _--..__J - -1 --------1 FOOD DISPOSER ! _! FLOOR/AREA DRAIN _ . ...__! � _.._� __ ! INTERCEPTOR(INTERIOR �! I . _.- I I I _.._._i 1 __— —___J KITCHEN SINK �! _ I _� !_.__.._.! f J .__.._.: . LAVATORY ROOF DRAINE-7-31 SHOWER STALL ! ._._. _ ! _I I __.I 1 I 1' _..._._1 _.__.._( ) _ _ SERVICE/MOP SINK TOILET -- URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATRR PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES .,.I NO IF YOU CHECKED YES,PLEASE INDICATE�THER OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY TYPE OF INDEMNITY EI BOND 01. 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 E-11 AGENT 10 SIGNATURE OF OWNER OR AGENT 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 co fiance wi ert' ent provision of the (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME / (LICENSE# IGNATU MP© JP _ CORPORATION FII# PARTNERSHIP # (LLC COMPANY NAMEi ADDRESS CITY STATE G► ZIP TEL --- Lam/--_ FAX CELL J-EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES w� z " - r" .r The Commonwealth of Massachusetts Department ofIndustrial Accidents Congress Street,Suite 100 Boston,MA.021'14-20Y7 www.mass.gov/dia 'O'tM SV•VV Workers,compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. -,plea a Print Le ' A licant Information ' / Name(Business/Oigabization/Individual): if�-� d?Ms Address: / D Phone#: City/State/Zip: Z :. ... .. : h«=. Are you an employer?Check the appropriate box: C--e li J Type of project(required), m ees fiill and/or part-time).' 7. ❑N&*'construction If]I am a employer with � . eP to y 2;AI am a sole proprietor or partnership and have no employees working for me in $. �Zemo delitig any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.❑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 11.❑Electrical xepavrs or additions ensure that all contractors either have workers'compensation insurance or are sole �TD.pinbing repairs or additions proprietors with no employees. 5.❑I am a general contracto and I have hired the sub-contractors listed on the attached sheet. 13•.E]Roof re)airs These sub-contractors have employees and have workers'comp.insurance.t 14.0.Other 6.Q We are a corporation and its,officdrs have exercised their right of exemption per MGL c. 152,§1(4),and the have no employees:[No workers'comp.insurance required.] *Any applicant that checks box#1 mti'st 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. compensation insurance for my employees. Below is the policy and job site X am an employer that is ptovidingwotkers' information. Insurance Company Name: Expiration Date:. Policy#or Self-ins.Lie.#: City/State/Zip: Job Site Address: 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 e.152,§25A is a criminal violation punishable by a fuie up to$1,500.00 enalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment,as well as civil p ay forwarded to the Office of Investigations of the DIA for insurance day against the violator.A copy of this statement m coverage verification. 7P�hhone reby c under,the ins d penalties of perjury that the information provided abo cis tt.e ander ect. Date: ure: #: official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions F` 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!A10', 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 ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver'or trustee 6f 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 employsersons to do maintenance construction or repair or p work o p n 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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 application for the permit or license is being requested,not the Department of IudustrialAccidenis. Should you have any questions regarding the law or if you are required to obtain a-si6rkers' 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 Iuvestigations 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 (i.e.a dog license or permit to bum 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 r ::COMMONWEALTH OF MASSACHUSETTS. • • su wtsha • • i rt BOARD Of PLUMBERS:' A1D GASF ITTERS; � py ISSUES THE FOLLOWING<. ]OENSE LICENSQ AS A JOURNEYMAN PLUMBER J \! M MICHAEL R SIROIS" E �1 . er `! 39 HAWTHIONE ST LYNN MA 01902-350 253 +7` 05/0]/]6 214898 I ervo niaEoFnaivv vca_:�, — u� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTIN- G (Print or Type) NORTH ANDOVER Mass. Da Cl kuilding Location Permit # Owners Name ' New Renovation Replacement Plans Submitted D FI XTUR=S N � W N a t- a � S t— C rn 1 O V W M Z N � f- a r z f- o t- a o w w w 0 O a � W W �1 `a m to r o }- �1 to y 4 N t3 1° m s z o w W tu to ; Z a x a cc a a us } m O t• :Z J N 2 W W O ? LL 1- .t i• W 2 4 W -.4 cc f' > G! O 0 N Y d yr y C tsJ O 2 4 G 4 d O O w cc O ul F- >z z O C1 U. n Q a. 1— o SUQ—BS�.1T. t BASEMENT f 1ST FLOOR 2ND FLOOR G1 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) Chec ne: Certificate Installing Company Name Corp. 'J 1b Address °3/ /��Z� - - Partner. Firm/Co. Business Telephone: • 0/� Name of Licensed Plumber or Gas Fitterj� Insurance Coverage: Indicate the type of insurance Covera e by checking the appropriate box: Liability insurance policy Other type of indemnity F BondEj 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 coverages. Signature of owner/agent of property Owner F� Agent D 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 perforated under Permit iuLed for this application will-be in compliance with all pertinent provisions of the Massachusetts Slate Gas Code and chapter 14I of Cho General Laws. By TYPE LICENSE: Plumber Title G.asfitter Si.gnatur/e o Licensed City/Town: Master Plumber or Gasfitter Journeyman APPROVED (OFFICE USE ONLY) Lice se umber Date . ... .............. 2 'k0RT14 TOWN OF NORTH ANDOVER 0 0 PERMIT FOR GAS INSTALLATION �,SSACHUSES This certifies that . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . ... . ... . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . .t .: . . .' . . . . . ... . . . . . . . . . . . . . . . . . . . . at . ... . .... . . . . . . . .. North Andover, Mass. Fee. . . ... . . . Lic. No.,. . . . . . . . . . . . . . . . . . . . . . . . . ; . . . . . . . . . 12/08/% GASINSPECTOR 08.45 WHITE:Applicant CANARY: Builk.'9'Dep?.RID PINK:Treasurer GOLD:File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 GASFITTING ,.'(Print or Type) / s NORTH ANDOVER Mass. Date �! /✓ 4uilding Location /'� /l��u� Permit # Owners Name > New —1 Renovation Replacementj �lans Submitted FI XTUR-c N � W N us4�1 p V a N tot z N O W W w a O Q 0 W W d m H Y O t' ILAC4 C5 _ t— to N CC W z U W 07 W 4 Q 0 a h X W W0 < z a e: cc W W t� s W L's d p > W h- V j W 2 d W O O N = a ,u > a W z Q a .4 0 0 `w — o W P ¢ = 0 0 U. :3 3: G 0 .s Q rz > Q a F- o SUR—BS:dT. BA, srz TENT t ST FLOOR 2ND FLOOR GI 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR TTH FLOOR 8TH FLOOR (Print or Type) � L%v`r Check one: Certificate Installing Company Na e Corp. Address , - S Partner. �jlQyl Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage_: Indicate the type of insurance coverg4e by checking the appropriate box: Liability insurance policy her type of indemnity Q 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 coverages. Signature of owner/agent of property Owner L� Agent M 1 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 perfornud under Permit isseed for this application will-be In compliance with all pertinent Provisions of the Massachusetts State Cas Cade and Chapter 142 of the General laws. By _TYPE LICENSE: /4� ulrtber / Title Gasfitter ignat/2r c Licensed CitIf Master Plumber or Gasfitter City/Town: O Journeyman APPROVED (OFFICE USE ONLY) Lic_nse umber Date. . �. .. c Of NORTH ,ti0 TOWN OF NORTH ANDOVER 3r O '� PERMIT FOR GAS INSTALLATION FA � r a 4 J ° Sr try �,SSACNUS�S This certifies that . . . . . .�. . .'" . . has permission for gas installation „� r'��%. . . • . . . . • yj in the buildings of . . . . . . . . . . . . ..f .. . ._. >. . . . . . . . . . . . . . . . at . . : �. . . �. ,j,F2t �! , . . . , , North Andover, Mass Fee. Lic. No.. . C. . 7 . . . . . . . . . . . . . . . . . . . . . . . . .� GAS INSPECTOR WHITE:Applicant'') "CANARY: Building Dept. PINK:Treasurer GOLD: File f 3 5 1 8 Date..7....3/-•�• .. .. r i HORTM TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 4 + • . h •�i,� °+,..°•'•,fit SACHUSE This certifies that . .C ��,.. .�� ./ �. . . . . � . r 1. �.z... . . . . . . i has permission for gas installation . .lam( . . . . . . . . . . . . . . . . . . . in the buildings of . . f�' L . . . .�1. .2 .f.` �. . . . . . . . . . . . . . . . at North Andover, Mass. Fee., . a. Lic. No.. GAS INSPECTOR WHITE:Applicant CANARY:Building d pt. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or A (� , Mass. Date c� _W20`0 Permit # ' P n � � e BuildingLocation I tt O d Owner's ame P i G m I Type f Occupancy New ❑ Renovation ❑ Replac ment Plans Submitted: Yes❑ No ❑ N m N W in Y Z Q N N N V � F- X N tt W m 0 O N = F W - W rt O U C1 -j CL F- Q Y Z Z O Y w o 6 m w H y w O O a. � N W < _ = F.. 0 O > W 0 � W Z U W ¢ N W ¢ W F- W H = C W W N J Q y W W O O > LL F— U J (A W C7 F Z J E' Z F- F- N m Z o W o N S 'i O = u7 C7 J U e > o a Fes- O SUB—BSMT. f BASEMENT ( I 1STFLOOR + _ 2ND FLOOR 3RD FLOOR I.I 4TH FLOOR i STH FLOOR I 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name ��Check one: Certificate Address CLIMATE DESIGN lam' Corporation reet Haverhill, MA 01930 — ❑ Partnership Business Telephone (978) 372-9999 ❑ Firm/Co. Name of Licensed Plumber or Gas `itterufllber: Michael H. House INSURANCE COVERAGE: I have a current o ❑ ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity O 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: Owner❑ Agent ❑ Signature of Owner or Owner's 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 the permit issued for this application will b in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gener w By T of Ucense: } " Plumber MSiere of Licensed l�u o r Gas Fitter Title e �'asterUcn Number City[Town Journeyman APPROVED OFFIC S.ONL r /.,.. ..3 9r r t',i _ .... ... t . ... ,.. - . `.'tt•'r.tvr."y.-`.re4'�'...r...f.,nr+p,.y.''i.1 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME 3 TYPE OF BUILDING 1 LOCATION OF BUILDING PLUMBER OR GASFITTER _r LIC. NO. PERMIT GRANTED DATE 19 GASINSPECTOR