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HomeMy WebLinkAboutMiscellaneous - 12 WALKER ROAD 4/30/2018to nounsin n� UWA1w r r m i O r O N O U cQ ERRI D � U (0 N U N C M N � C) N -2 Ivry W `1 U N O E U Z — M 0 co U � c �o � Q O ca E p O o Z LL r N c c m _ 0 Q 0 O -E Z �+ W^ EQ Z a. � a o O > `m F— M cn = CO Q c U ca of N Q Z o E E O O E co = It N cn O 0 Q M 0 C -0 w w T T � J CO co L O N �_ V • "C LLN L 10423 This certifies that ..4�A.&�.k.1 ........... C4 ....... hasermission to perform .... . ...... p ... W.) ....... Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING plumbing in the buildi gs of........... ....................... Fee,SO.!� ... Lic. No. Check # .................................................................................. ................ N rth Andover, Mass. ... ... .. .......... ............................................ PP�LIUM��B�I G INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY /V ndaw i MA DATE ,2 iy a� _( PERMIT# JOBSITE ADDRESS OWNER'S NAME Shaw r POWNER ADDRESS TEL -I-FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES ® NO® FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICEI DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01USAND SYSTEM I —11 _A _.-_ _ i _ I _. T= ,_ ,I - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM 1 I . _-_ [ _ E 1 1 __ ._ [ 1_31= DEDICATED WATER RECYCLE SYSTEM [ _._____� _._..__I ____. _._� __.__._! -___► -_J ._...___i ____( __ _[ -� DISHWASHER . f [ .__ � _.__._-I DRINKING FOUNTAIN �I � __--[= _ FOOD DISPOSER i I f -_ _-----} __.--- ----f __. FLOOR/AREADRAIN 1 ___ (--_ ► _-___ _._� (_...___s Y__.} .___._� ___1 ._ _._ __ _._ ! _I _____-� INTERCEPTOR (INTERIOR) KITCHEN SINK-1-11C.__J __ _— ___! LAVATORY i _ ._._._! ROOF DRAIN f _? ..__.._...( 1 ___.___.4 ____--,j .____.,.I ____i ___ i ...--_ .-( SHOWER STALLSERVICE oil, /MOP SINKITOILETi URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _i J _ - I i WATER PIPING I I ._....... __--.� INSURANCE COVERAGE: 1 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 POLICYDi' 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El AGENT SIGNATURE OF OWNER OR AGENT 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 General Laws. PLUMBER'S NAME LICENSE# 07 6� a I SIGNAIRE MP M JP 0 CORPORATION F1 PARTNERSHIP ©# s LLC j COMPANY NAME i ADDRESS 733 1urn :`k CITY /�. n�oVC/- .._..__._..._[STATE A _� ZIP �1l Y 11 TEL 4/O_30 )c12 FAX CELL �� EMAIL o o z w rL ui w LL The Commonwealth of Massachusetts 07 Department of Industrigl Accidents Office of Invesdgations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ,Applicant Information PIease Print LeWbly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have Hired the sub -contractors listed on the attached sheet. # F1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10. El Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL I L ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance required.] i employees. [No workers' 13.❑ Other 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 ace 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 sub -contractors and their worker;' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company N Policy # or Self -ins. Lie. #: 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 requiredunder 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 and penalties ofperjury that the information provided above is true and correct Simature• Date: Phone #: 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. PIumbing Inspector 6. Other - - - Contact Person: Phone Information and Instrnctions 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 -contractors) 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 maybe 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 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 he. 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 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 aiid fax number: The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel. # 617-727-4900 eyt 406 or 1-877,MASSAF.B Revised 5-26-05 Fax # 617-727-7749 www.mass,govfdia Date 0.11C ............... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that,.4 �/ P� ' ¢" .... ...:... has permission to perform / -7� �S wiringin ,the building -ofe..L........................................................................................................ at �" u „ s �''� /f�...... , North Andover, Mass. Fee Z �.......... Lic. No. IDSA IV14--- ............... ELECTRICALINSPECTOR Check # Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 11 bid BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (AMC), 527 CMR 12.00 (PLEASE PRNT INNK OR TYPEALL INFORMATION) City or Town of: NORTH ANDOVER By this application the undersigned gives notice of his or her inti Location (Street & Number) Owner or Tenant ill t ei C,i ;1 Date: To the Inspector of Wires: :on to perform the electrical work described below. Aprn e-0 Telephone No. Owner's Address SOJnE Is this permit in conjun tion with a building permit? Yes El No El (Check Appropriate ]Box) Purpose of Building 5 ► p �� Utility Authorization No. - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: a /7d GJft// J UQ d, I& 1 � �� bOp,7,1, t J7, Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters r%Jpfl—c 6#9 L( , &ALJ CC--iiyn CGmS— 6ox 7W Completion of the following table Aay be waived by the Ins ector of Wires. No. of Recessed Luminaires No. of Cell: 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- ❑ rnd. Rrnd. No.of Emergency Lighting Battery 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 Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number .--'.""""..... Tons KW """""....... No. of Self -Contained 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 No. of Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: 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: Q �, (When required by municipal policy.) Work to Start: ,3 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C GE: 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' coverge 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 eci ❑ (Specify:) X certify, un der the pins and penalties of perjury, that the information o this application is true and complete. UZ FIRM N �ti !7 L QQ,e �Q t ~`. LIC. NO.: / D 3.3_m Licensee: k'NyL0�y�,QQ/t,� Signature LTC. NO.: 4'/ J (If applicable enter"e empt" in the license numberline) )i- - Bus. Tel. No. • d 3 .93 0 % -?Y4Address: .�o`16 P14 � // rS 5 OUA6 Vl.l *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 normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: � Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INS 10N - Pass Failed 0 Re- Inspection Required ($.) Inspectors Comments: 6� � = L •3 Inspectors Signature: X Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.masss gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Orgaai'zation/Individual): t /t 0 L City/State/Zip s) t" 1 J jc' . , QoCI - Phone #: 6a 3- AreXu an employer? Check the appropriate box: - Typo of project (required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t 7• Remodeling ship and'have no employees. These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9, 5. ❑ We are a corporation and its ❑ B 'ding addition [No workers' comp. insurance required.] officers have exercised their 10. Electrical repairs or additions 31. ❑ I am a homeowner doing all work right of exemption per MGL 11. F1 Plumbing repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[j Other comp. insurance required.] Mny applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. Homeowners who submit this affidavit indicating they ire 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 sub -contractors and their workers' comp. policy information. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. 3ee– (,,��— Policy # or Self -ins. Lic. #: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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 -t& violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. X do hereby c cider thepain;nctpenaldeso�perjury that the information provided above is true and correct. Phone#• /,v a3- ,23y 23 4r Offccial 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. PIumbing 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 j oint 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) andphone 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 maybe 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 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 he. 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. Anew 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 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 010MM AW—Dalth of Mfassachmetis Depaxtment of ludustdal .Accidents QfRoe ofIuvestigatiom 600 Waftgtoa Stwa Boston? MA, 02111 TOL # 617-727-4900 oxt 406 ox 1.-87 MASSAF.F Revised 5-26-05 Fax # 617-727-7749 E 1: COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS ASA REG JOURNEYMAN ELECTRI CIA' ISSUES THE ABOVE LICENSE TO, -i ARNOLD M GREENE m s 326..-WE-ST HOLLIS ST NASHUAN H 03060 3.053 1813JR 07/31/13. 85.9340 AI Date. !' /7 ".6� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...'....:---t'"�-�!-!`'�............ `has permission to perform .. : JZ' -'-"'t' y .............. . plumbing in the buildings of ......`........................... . /� Z`f u at ............................ �'� ...... ,North Andover, Mass. Fee ......... Lic. No. .. :.. �. �:� .... � . .............. . INSPECTOR Check # 'IyZ Z" 5626 n.\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type Mass. Date U!-6�'1��' G. Permit # A1zye-?,,^. ,l . ` /1��� ' Cwner's Name er Building Location i_ �. ,yC/ - t' `'� IlYe Type of Occupancy 2 S 117 E �1 -h A L - IN New ❑ Renovation ❑ Replacement tld' Plans Submitted: Yes ❑ No ❑ FIXTURES Installing. Company Name P50 MeT _� Si0a1M#4TA6Q Check one: Certificate Address ��f? Vit?!-}C14�) s-� ❑ Corporation, al E TN12 67N, Yo A ❑,,Partnership Business Telephone ���7 Z -5tq'7 1 9-FItmxo. Name of Licensed Plumber Fe -r- req en INSURANCE COVERAGE: I have a currentfiablifty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If If you have checked yes, please /indicate the type coverage by checking the appropriate box A liability insurance policy kd 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: Owner ❑ Agent ❑ or 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 ormed under the permit issue-4for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral Laws. By SWITire of Licensed Plumber Title Type of License: Master % Journeyman ❑ City/Town - � - APPROVED (OFFICE USE ONLY) License Number z 5 Z N < N y y Z p Y Z = W W J N Z O =` M. NWY Z N < � _ N Z _ a W QO _p= O W W Q ycc W xpO 1 J Z Y U. VN 0 z sNO G oN O>_ W o 0X 2SWZ <HV << s: 0 Q< O Q J Q Ic cc a< S O< F- Y. Q C m O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing. Company Name P50 MeT _� Si0a1M#4TA6Q Check one: Certificate Address ��f? Vit?!-}C14�) s-� ❑ Corporation, al E TN12 67N, Yo A ❑,,Partnership Business Telephone ���7 Z -5tq'7 1 9-FItmxo. Name of Licensed Plumber Fe -r- req en INSURANCE COVERAGE: I have a currentfiablifty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If If you have checked yes, please /indicate the type coverage by checking the appropriate box A liability insurance policy kd 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: Owner ❑ Agent ❑ or 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 ormed under the permit issue-4for this application will be in compliance with all pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral Laws. By SWITire of Licensed Plumber Title Type of License: Master % Journeyman ❑ City/Town - � - APPROVED (OFFICE USE ONLY) License Number z 5 f :x t 1 N X A D It .V m .r - A z o m p` 10 Z 7D M O O. �1 A o c N o O r z c x m z p