The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 13 ELMWOOD STREET 4/30/2018 13 ELMWOOD STREET 210/006.0-0023-0000.0 VV d .. � Date...N...WYY........ 10843 RT#j TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ' ¢. This certifies that...��C�................................................................................................................ has permission'to perform..../. ..7 .kj KAS ..................... ........................................................... plumbing in the buildings of /657 � ......4 Q ......IZ6 .................... at......./3.......4.—/Oer. .............. North Andover, Mass. ............ ..... ..... Fee./Y�2 .....................Lic. No ...... ............ ................................................................... PLUMBING INSPECTOR Check V-y, b �\y 'oq PW 1myll s MASSkCHUSETTS UNIFOO APPLICATION F R A PER IT TO PER ORM NUMBING WORK CITY NAHJ ai„bio ram n MA DATE PERMIT#E JOBSITE ADDRESS �� -dJ ,� jo a fl OWNER'S NAME OWNERADDRESS jVti! Su f St' M&,4j 97k4jj-44aVFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB t CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN q. SHOWER STALL 1' SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION 9—Z -'NATER HEATER ALL TYPES t. 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 ❑ r 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 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 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# SGNTTUUR—E� MP[ ] JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME N f" ADDRESS t ML ht mg&h aid CITY LAP/ ' ®® STATE ZIP �/�(�i Q� TEL FAX CELL 4°7 8—2PLI-S M9,EMAIL A AA/tio As Q��e-)U Ne t E The Commonwealth of Massachusetts ' YDepartineltt of lndustrial.Accideiz6 Office of Investigatlohs-" U1J` 600 Tt1riFSliilzgtoF! Street, JJ Boston,MA 02111 Fi Date...Z!Al ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU This certifies that._............ .................................................................... has permission for gas installation X.............1........ t........ .. ..........✓ ..... .. .. ......... in the buildings of.. at... /J�:... .. � ..`.'` z ........................................... North Andover, Mass. Fee ..... Lic. NoJ ....... /W.......................................................... GASINSPECTOR Check# 9639 lbjjyd C cP --T-_ MA 4,T - JOBSITE r ��,;,,; SSACHUSETTS UNIFORII(I APPLICA" 0(`t FpR A PER(UIIT TO PEP,FOR G, S FpRK ^� CITY ®1"`! I� �[P��lMA DATE � PERMIT#ADDRESS, l3,ELM .4V,00 p P J_ OWNER'S NAME. S ° OWNER ADDRESS L FAX VV4 -+`g/'�7 TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL rJ CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOE] APPLIANCES I FLOORS -E—M 1 2 34 5 6 7 8 g I 11 12 13 1q BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCI(S MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER 6;NVENTED ROOM HEATEP, WATER HEATER OTHER INS ANCE ERAGE I have a current liability insurance policy or its substantial equivalent whichmeetshe requirements of MGL.Ch.142 YES ❑ NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY [A OTHER TYPE 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I hereby certify that all of[tie details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME DIN10/b &40/ft a LICENSE# Q � SIGNATUREP� MP� MGF❑ nJP❑ JGF❑ LPGI❑ CORPORATION❑;t PARTNERSHIP❑# LLC;e# COMPANY NAME ADDRESS 10 CITY L. 1 STATE zip tq I 9&6 TEL FAX EM CELL AIL �j — �&A he `.(1:3€f!€OnweCf'kh o/cTt assCeCi u—,elvi's Departmen! of Indush icl-Acciden s Of-tee o� �p€z eStP�qt€oris 600 OFloshincton StreetBoston M4 02111 t. u tv,vei�.massgovIdia Workers' Compensation Insurance Affi alvilt: Buildei-s/Conic•aetoi-s/Electricians/Plumbei-s Applicant Information Please Print Legibly Name (Business/Organization/Individual): ,N E A4 Address: 3 bitcI7AD City/State/Zip: IV— Phone#: -? Are you an employer? Check the appropriate box: Type of project (required): ❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New constriction employees(full and/or part-time).* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition ,. working for me in any capacity. employees and have workers' 9 Building addition i [No-workers' comp. insurance comp. insurance.1 re wired. 5. ❑ We are a corporation and its ME] Electrical repairs or additions 9 ) .❑ i am a homeowner doing all work officers have exercised their I L# Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, ;1(4) and the have no 13. Other- employees. ` 1'Jo workers' ❑ [ l comp. insurance required.] ury applicant that checks box M must also fill out the section below showing their workers'compensation policy information. -lomeowners who submit this affidavit indicating they are doing all"lork and then hire outside contractors must submit a new affidavit indicating such. i 'ontractors that check this box must attached an additional sheet shoving the name of the sub-contractors and state whether or not those entities have i rployees. if the sub-contractors have employees,they must provide their workers'comp.policy number. 'z?n an employer that isprovidino worlters'compensation insurance for mi,emplovees. Below is thepoliq airdfob site { f formation. surance Company Name: FA-JtJU AIM/ Iicy it or Self-ins.Lic. #: Expiration Date: rb Site Address: City/State/Zip- trach at copy of the workers' compensation policy declaration page (showing the policy number 2nd expiration date). -)ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tie 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for insurance coverage verification. c/o hereby certify under the pairs andpennalties ofpe►jury that the information providedabove is trite acrd correct. ignature ! _ _,f' Date hone#: Official iiye only. Do not write in this area,io be completed by city or totv,, offaei?L City or Town: P ermit/FBicense# Issuing Authority (circle owe): 1. Board of Health 2. Bu' ildina,>!iepartrnent 3. City/Town Clerlt 4. Elecirical Inspector" S. Plumbing Inspector 6. Other Contact Person: phoac #: I 1 t �1 r :�>aVM1Y1V1VYVCHLI I`I Vt M:. �.�f±►4riV�G�i r:�. BOARA QF PLUMBERS AN17 GAS,F ITTER- ISSUES THE FOLLOW I:NC..L I CENSE.;;:.:. I_FCENSEDAS A MASTER PL1MBERs DAVID H BAB INE �f s•l. r . 30 B I RGH >MADOW RD W. Mi:ftR i MAC _1A o1860- 9: 1860 980 05/01/16 199368 f. )ate.... ................ V-K— P -5 RTH ANDOVER d�h50.ry � QR WIRING ( AJ ........................................ �� .................... ...... ........... A e- ....................................................... .... jorth Andover, ass. fth . . . ............ ELECTRICAL SPEC Check# 127 0 ! � ( Date....�...�........... ................. e OF &ORTN,� oo� TOWN OF NORTH ANDOVER 0 9 PERMIT FOR WIRING 3�CHU This certifies that .... ...... �" .... ....................................................................................... u r JL haspermission to perform ............................................................................................................. H�S J�e' wring ' the building of........! ...... ............................................................................. a .. ....................... orth Andover, ass. . ....... ,nnu,C)U -.............o J _Q� Fed....:..-�!,.. Q ?,...�.....Lic.No. .. .. .... .. ............. ELECTRICAL NSPEC Check# 2n 70 Commonwealth of Massachusetts Official Use Only ' Department of Fire Services . Permit No. K061 Occupancy and Fee Checked 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(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: I '—j— ( q City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform a electrical work described below. Location(Street&Number) ,,- ( t/,e-S Owner or Tenant earrlear LTelephone No. Owner's Address _!tit .,�,.eA ,,L nj— Is this permit in conjunction with a building permit? Yes P No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No./ 9 7 5 9! - Existing Service,6n) Amps Volts Overhead Undgrd❑ No.of Meters New Service ;oq Amps lAcl /ae1CJ Volts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 15- 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- ❑ o.o mergency ig tmg rnd. lZrnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRI♦;ALARMS No. of Zones No.of Switches /L,5— of GBurners No.of Detection and I� as Initiating Devices G� y ^6 No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers f Heat Pum Number Tons KW No.of Self-Contained r Totals "'' ....... """...""..""""' 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 No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent !� No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: -1 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. EeTSURANCE 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 BOND ❑ OTHER ❑ (Specify:) Xcertify,tinder the ains and enalties ofperjury,that the information on this applicaf' n is true and complete. FIRM NAME: . DC7-i c ac -- LIC.NO.: Licensee: t O,,L Signatur LIC.NO.: ,2 (If applicable,ent r "exempt"in the license number line) Bus.Tel.No.:7 767 '60 3�� Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Departmen 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 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 t 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 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: p g PARTIAL ROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors Comme ts: Inspectors Signature: V Date: FINAL INSP TION: Pass V Failed Re-Inspection Required($.) ❑ Inspectors Comments: n, Inspectors Signature: W14A Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com A 1 1 ♦ ' The Commonwealth of Massachusetts , - Department oflndifstriglAccidents Office offnvestigations 600 Washington Street Boston,MA 02111 www.massgovfciia Workers'Compensation hisurance Affidavit:BuiXderes/Cont°actorslElectr iclanslPliimbers A heant Information Please Print Led.1 Name(Businessiorgauizationadividual): �� G�f z L �•L C- Address:L/� dcc City/State/Zip:i�Ce_uc_e.- dA 01S'` Phone#: Are you an employer?Check the appropriate box: Type of project(required): .[{,I am a y emP to ex with 4. ❑ I am a general contractor and I � havehiredthe sub-contractors 6• New construction '''employees(full.and/or part time). 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and'have,no employees These sub-contractors have 8. Demolition worldug for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ElWe are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised.their 3.[( I am a homeowner doing all work right of exemption per MGL ll.[]Plumbingrepairs or additions myself[No workers'comp. c.152,§1(4),andwehaveno 12,❑Roofrepairs insurancerequired.]t employees.[No workers' comp.insurance required.] 13.E]Other xAny applicautthat checks box#1 must also fill outthe section below showingtheir workers'compensationpolicy information. 7-Homeowners who submit this affidavit indicatingthey o're doing all work and then hire outside contractors must suhmit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name o£the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'cornpe�zsation ir�su�ance foY Yr�y eYnployees Berow is the policy and job site information. Insurance Company Name:. Policy#or Bel£ins.Lic.#: Expiration.Date: Job Site Address: City/State/Zip: Attach,a copy of the workers'comp ensation•p olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as requI dunder Section 25A ofMGL 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 fm 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. Ido Xiereby cert' r the pains and pen of perjurer tliat the informrction provided abo a is ue and correct. - / ax L /G Si atuxe• �—� Date: Phone Oficial 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.CityMown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - Colitact Person: Phone 9: •t , Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuaat to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,- express orimplied,oral orwxitten." 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 ente rise,and including the legal representatives of a:deceased em to er.or the � g g p p y,.�. 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 employes." MGL chapter 152,§25C(6)also states that"every state or local lie-easing 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting aufhority." 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,axe not required to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required. De 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 thepermit 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 obfiain 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 andprinted 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 pormit/license number which will be.used as a reference number, Iu addition,an applicant thatmust submitmultiple 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 towiz)"A-copy of the affidavit that has b een 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 orpermit 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: Tho Commonwealth of Mama ft xspjtts - JDepar eutofIndu*ial,Accidonta Qffioe ofX)Rvestfptiona 60 WasWV. oa kod Boston, .021 It TO,#6174.27 4.900 ext 406 ox 1-87-7-YA-SSAFE Revised 5-26-05 Fax#617-727-7749 Wwwaaagovaa. 1 r r Commonwealth of Mas usetts,. Division of Registrati Board of Electri RYAN M E £ 45 ADA W LAWREN Master Elec ' 'a 0 21726-A '67/31/2016 008835; License No. Expiration Date. Sena/No. Date..! : �.G.y. .. .. . . pf TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION • _ a ,SSACHUSEt - I This certifies that . . . . .'�? . . .. . . . has permission for gas installation . . . . . . . . . .. . in the buildings of G zz . . .!2 . . . . . . . . . . . . . . . at L . L`'"-. . . . . . . . . . . . . , North Andover, Mass. Y Fee, -. . Lic. No.. ? !! . . . . . . . .�..L�1;� . . . . . . . . . GAS INSPE Check# 3��'�� 5. 6652 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) ` H L K 43000 L , Mass. Date j 2 5 D _ Permit #—LLLZ Building Location , �i �LII( )17ap ST owner's NamekLU N Mi (11 E )A P-D KfOPI-TH Type of Occupancy_ kL I OLNT I AC -51 MG(k New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No❑ 1 N � _ cc N W N N Y Y d N N a N Q 0 y = Fz- W W J N W 0 0 m ~ •� s �A tl } Z Cr a 0 W Q ¢ ct ZO O a r w 00 0 W h W_ W O a G h U) 0 cc W z V W N z Q G: 0. a > W W W Vf J Q = rr cc W f. W f.. x H a z Q W J Q L ~ h 5. 0 m z O z WR. N W h Q , > D: W 7 2. Q Q Q 0 0 W O \ ¢ .x O tl Y LL 3 o tl .� V C > p a h� O O� SUB -- BASEMENT I f !ST FLOOR IT 2ND FLOOR 3RD FLOOR ti 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET �O Corporation 1862 LAWRENCE, MA 018 41 - 2312 ❑ Partnership Business Telephone q 7$-6 8,7-110 5 EXT *306 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: " I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy P< Other type of indemnity❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner'sgent Owner❑ Agent Ell� 1 hereby certify that all of the details and information I have submitted(or entered)in abo plication are true and accur to to the best of my knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpIianoe with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene U i T e of License: Title Plumber Signature of cen Plumber or Gas Gasfitter Cit /Town Master License Number 374 5 ICSE O Journeyman i. BELOW FOR OFFICE USE ONLY PROGRESS INSPECTION FINAL INSPECTION SKETCHES FEE NO. APPLICATION FOR PERMIT TO ADO GASFITTING M� NAMES TYPE OF BUILDING LOCATION OF BUILDING { PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE GASINSPECTOR