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HomeMy WebLinkAboutMiscellaneous - 135 MASSACHUSETTS AVENUE 4/30/2018 135 MASSACHUSETTS AVENUE 210/006_=-0000.0 / I i I MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(8001851-8424 3/19/2016 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: SHARON LAFLAMME Property Address: 135 MASSACHUSETTS AVENUE, NORTH ANDOVER, MA 01845 Policy Number: 0819218 Type Loss: Windstorm Other than Hurricane or Tornad Date of Loss: 03/17/2016 Claim Number: 405183 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. MPIUA Claims Division CMA00021 Date. 9535 R7:��° TOWN OF NORTH ANDOVER �? •` °c 3. ° - PERMIT FOR PLUMBING s ,SSACNUSE� This certifies that . . . . . .."'. . . . . . . . . . has permission to perform . . . -� �? . . . . . . . . . . . . . . . plumbing in the buildings of . . . . .. . . . . . .. .! . . . . . . . . . . . . . . . . . `rr at . . .��J 1Z�-55. .A.e :. . . . ., No And,'er Mass. Fee. .�.�OO.Lic. No..�©.P4? . . . . . . . . . . ,r PLUMBING IN PECTOR Check Au g. 10. 2012— 8:46A ' ii, . o I j 1—r. t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORA I GAS FITTING WORK CITY MA PATE Pft IT# JOBSITE ADDRESS _ — OWNER'S NAME OWNER ADDRESS S TE FAX TYPE UR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENT IAL PlIW CLEARLY NEW:Lj RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES® NOL] APPLIANCES 7 FLOORS-- BSM 1 2 1 3 4 5 B 7 6 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE IE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTEO ROOM HEATER WATER HEATER OTHER - - — INSURANCE COVERAGE I have a current Habilily insurance policy or its substantial equivalent which meets the requirements of MGL.CK 142 YES UNO 13 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1 OND �]J 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 wWives this requirement. CHECK ONE ONLY: OWNER ❑I AGENT L3 SIGNATURE OF OWNER OR AGENT I hereby cerury that all of the details and information I have submitted or entered regarding[his application are true and a ate to the best of my knovAedge 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 Massachuseus State Plumbing Code and Chapter 142 of the General Lens. PLUMBER GASFITTERNAME �p�w,o� �e4-.,� a_ LICENSE# 0 h SIGNATURE MP&M' GF 0 JP CI JGF F-j LPGI[j CORPORATION[]# PARTNERSHIP LP _ LLC[3# COMPANY NAME: ADDRESS CITY STATEZIP b TEL FAX L CELLI- EMAIL _ i Aug. 10. 2012 8:46AM No. 6137 P. 2 The Commonwealth ofMassachusetts Department ofXndustriglAccidents Office of Investigation 600 Washington Street Boston,M4 02111 www.massgovldta Workers' Compensation Insurance Affidavit:Builders/Contlractors/,Iectlricians/Flu mbelrs Applicant Informations Mease Hutt Leelb�v Name(Businesdorganlzatton/individual): Address: &"czsV ci City/State/Zip; C4 phone#;4 W6- Arra you an employer?Cheek the approprlate box: Type of project(required): 1•LTA&n4 a=Tloyor with._ 4. [(I am a general contractor and I 6, [1 Now construction f employees(full and/or part time)." have lured the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.i 7� E]Remodeling ship and'have no employees These sub-coutractors have 8, Q Demolition working for me is any capacity, workers'comp.insurance. g_ Building addition Wo workers comp,insurance 5. Q We are a corporation and its required.] officers have exercised their 10.Q Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L[]plumbing repairs or additions myself.[No workers'comp. c, .152,§1(4),and we have no 12.Q Roof repairs insurance required.)t employees,[No workers' comp.insurance required.] 13.[]Other !Ally applicant that chocks box#1 must also fill out the section below showing their workcrs'compensation policy information. t Homeowners who subrltthis affidavit Indicating they ak doing all work add then hire outside contractors must submit a new affidavit indteattagsuch, tGontractors that checkthis boxmust attschcd an additional shectshowingthc name ofthc subcontractors and thea workors'comp.policy information. I am an employer that Isproviding workers'compensation insurance formy employees Below is ihepolicy and job site igbrmaduft. p I Insurance Company Name:, policy#or Self-ins.Lic.#: Q or 3 ter'7 l a Expiration Date:-A— 13 lob Site.A,ddzoss: ti City/State/zip:_-Xkap Attach o copy of the workers'compensation poltey declaration page(showing the poltey comber and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.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$250.00 a day agalust the violator, Be advised that a copy of this statement may be forwarded to the Offico of Investigations of the DIA for insurance coverage verification. I do hemby cexto tartlet'the pains andpenalttes of perfiury Aat the 14&rmadonprovued tab0Ve is true and correct, Signature: Date- Phone#: B/DCS of,octal rise only. Do not Tvrite In this area,to be completed by city or town of`lehil City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5,plumbing Inspector 6,Other - - - Contact Person:. Phone#: MASSA HUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Pih0or Type) L� Date Per it J� Building Location 3 �A;wne s Name Type of Occupancy_ New ❑ Renovation ❑ Replacement W-#*#' Plans.SubmKted: YesEI No.,p V1 N W k W N N N V F, OWC N Q N W O W W143 .r Z, 1.. a ` m Yr i W ui 0 H Q. C r .~( N 0 7: 7:$A 01 .4 O � W W W N J < Z AC K C) OC W h W t _ J iC I{lj /W us W0Y OXZ .4 W } WO U. Y W 'Cx V b 0 7 ` sue—BSMT. - BASEMENT 1 1STFLOOR 2110 FLOOR 9R0 FLOOR ' 4TH FLOOR ' STH FLOOR STHFLOOR 7TH FLOOR STH FLOOR Insta111rip:Company Name., D .'8 PU All8lW Check one: Certificate # Addressn SALEYa N� r� ❑ Corporation Partnership Business Telephone L a Firm Co. Name of Ucensed Plumber or Gas Fitter oI CJ E INSURANCE COVERAGE 1 have a current 1lalSillty Insurance policy or its substantial-equivalent which meets the requirements of MGL M 142 Yes ®' No O It you have checked yrj. please Ind cele the type coverage by checking the appropriate box. A Ilablifty Insurance policy• Other.type,of.indemnil ❑ ' YP y Bond O , ,..1 OWNER'S INSURANCE WAIVER: 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. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent 1 hereby cerUly,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 1 a n plumbing work and Inslalla to oertlnant p g l ns perlormed under the permit Issued for this application will be In eompllana with all provislons of the Massachusells Stale Lias Code and Chapter 142 o1 lhs G!Grool Laws. a of Uconse: an PlumberSi§naluce o ce um or or as r er Tills � Claslillor � /� � / �y Zil /Town astor license Number Journeyman .. . .. .3)A^b M.• e.» N ... r e.♦n4r, n :t.. ,.xN- .. r. V � � ,� i���+�FRew�9�..��� ,. ...lam •?*#'.Yat r�`. __.._ • ,r3.� 4. • • t � � � Vii. i } f 6'-• „y,� "`.�. , �• A iyf„hz'�i� - N as 20 r � yp� 1+1 --dd ;;• o O wC. 'Y t 9 „y. sA> Nc : lk Location No.' � Date 4 i N RT» TOWN OF NORTH ANDOVER Certificate of Occupancy $ .� Building/Frame Permit Fee $ Z Foundation Permit Fee $ s�cwust Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTALC) $ 1 140 X00 RAID Building Inspector Div. Public Works PER-s11T NO. a APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. v PAGE 1 MAP h40.c2n LOT NO. 0 2 RECORD OF OWNERSHIP DATE BOOK :PAGE ZONE �I SUB DIV. LOT Nq i LOCATION olf I. PURPOSE OF BUILDING • �P OWNER'S NAME Z' 7 �� 1 / NO. OF STORIES f SIZE OWNER'S ADDRESS ! /�I,f5 ,-¢vE AO � BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING I' DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE 1 FILL OUT SECTIONS 1 - 3 E8T. BLDG. COST PE Q. FT. PAGE 2 FILL OUT SECTIONS i 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. + ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS i PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED BUILDING INGPRCTOR 81 NATURE OF OWNER OR AUTHORIZED AGENT 697-19 r > It FEE OWNER TEL.I/ 9 I PERMIT GRANTED CONTR.TEL.k p 19 .07 CONTR.LIC.# �4 H.I.C.# BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY SiORI S THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF'BUILDINGS. WITH PORCHES. GA. APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE _ 3 1 2 13 CONCRETE BL'K. PINE __ _ BRICK OR STONE HARDW'D PIERSPLASTER _ DRY WALL UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ Y. 1/1 '/, FIN. ATTIC AREA _ N_O 8M'T FIRE PLACES _ HEAD ROOM _ MODERN KITCHEN _ 4 WALLS I 9 FLOORS CLAPBOARDS 8 1 2 3 DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH _ ASPHALT SIDING HARDl"D _ ASBESTOS SIDING COMMON _ VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY _ STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR (- BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME SUPERIOR I-i POOR _ a. ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE I I HIP V BATH (3 FIX.) GAMBREL MANSARD TOILET RM. 12 FIX.) FLAT SHED_ WATER CLOSET _ ASPHALT SHINGLES LAVATORY , WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. STEAM STEEL BMS. &COLS. _ HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OI l B'M'T 2nd _ ELECTRIC lot 13rd I NO HEATING DATE(MMIDDIYY) CERTIFICATE #F: :fi181£11f:11If3At'IE ...... ............::......... ................ ......... ...................................... ..... .. 10/23/96 ..:::: PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION �Q gR,�gCE�GROUP ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Foy-Poliquit 0In? I'faZdenJUlte 103 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR aZd JU ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 130A�I COMPANIES AFFORDING COVERAGE • Salem,1'11 —3173 COMPANY A Commercial Union INSURED COMPANY Ed Lebrasseur B Residential Construction COMPANY 451 Shadow Lake Road C Salem NH 03079 COMPANY D lr A S......... THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITSLTR DATE (MM/DD/YY) DATE (MM/DD/YY) A GENERAL LIABILITY CMLF98785 01/07/96 01/07/97 GENERAL AGGREGATE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG $ 1,000,000 CLAIMS MADE F x1 OCCUR PERSONAL&ADV INJURY $ 1,000,000 OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE(Any one fire) $ 100,000 MED EXP(Any one Person) $ 5.000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ........................................ ....................................... ........................................ ....................................... ANY AUTO OTHER THAN AUTO ONLY: EXCESS LIABILITY EACH OCCURRENCE $ UMBRELLA FORM AGGREGATE $ I OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND WC STATU_UMIT- 0TH- EMPLOYERS'LIABILITY EL EACH ACCIDENT $ THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $ PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONSrLOCATIONS/VEHICLESiSPECIAL ITEMS FICATE..1 IOLOE '�............................ CELLA. :.: .:. ::;::::i::::::::::i::::::::;:i;:;:ii:i:;;:;:;:i:`:::;:::;:i::i::i:::::i::i:::::::: :: ::::::::::::::::::`: ..........................................................CANCELLA.WN................................................::::. :::::::::::::::::::::::::::::::::::::::::.:::::.:: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Sharon Mambro EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 135 Mass Ave 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, N Andover MA 01045 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Terri Tru hn ' ........:.................................................................:.:.::::.:::::::::::::::::: AC ::::::::. :::. ............. ... ..:....................................................::::...:::..:......:::::::::::::::::::::::::::::::. .......:::::::::::::::::::::::::::.::::::::::::::.1?c::..: "oFFlcFs OF. ' •K'' _`- = Town.of ..� ��_ ..,�,� _ �.. . '�r:� .izon�sainscrees - j -.North Andover.APPE—iJLS - NORTHANDOVER .Mashsetts o t s -= BUILD CONSERVATION DMISON OF HEALTH '^ " Pt�a.NNINPLANNING & COMMUNITY DEVELOPMENT :. KARE-N Hp`EL.SO`\ DIRECTOR i i Inwitha;.'te� c:s:c •tG�` -_VS condition of Buildirs Per-:it Number � s -het dzt,"s rcSultine -rcm this work Shall be disresed ci ... 7. rreper r - ;clid ;s _°�^^s:.. :�_.. ._.:..gid by .%1Gi_. c il.. S iae debris will be disposef' cc in: v V JtC:..: tU.'t Of PC.-MIL Acciicant �G z3 Date NOT=: Demolition permit fra= t:.e Tosra of North Andover must be obtained for this project through the Office of the Building Inspector. ..,:r TOWN pf. NO AFF AFFIDAVIT. cal- :Iaw F to:Pmt s -g e4 nres the'the in—r.r'rn� al ta, zaz ifla, °ter, vza s rn' Yt, ®coal,rd li tial,, cs �r- i� of an , tt�n'to:ay p� e dsdig irg-antazrnrg at list.me but not. ttnn fa c� 1 tuts-=-ar to stri i-*+* s�z a ad�� bo sum rnsd— e c�.hu1 g'•,l�drne'by ` n ' aIn�g`" other .. Q7',µ✓ 5''. f , c�y .�� p/ , 4 Type. of ;Work: i �S f1 Est. Cos DDIJ Address...of Work 142 Uwne= Name. / Date of Permit Appl.icat on /O r Registration is not- required for L foll9 uigsreason(s). of ee [ee �zly, . r Wo r excluded.by last Job lender1 000 { f r } �y -.no t�q Downer-occupied e ,'p-L l ing win i1PT'CLIl - Othei' (� Y. Notice is "hereby given that: . OtrNERS PUIIZNGR {7G+Z4 kPEFtir OR 'DEALING WTIfi IINREGISTERED CIJNIRACIORS_ FOR APPLICA$U:LOSE II�FR YT WpRK,D0.IVC7t SAVE ACCESS TO THE ARBITRA TION PROGRAM r'R QJARANIY.; 1ND IJiaiER ISL c. 12A Y Sid u-&,— es af:per I .hereby apply for a perm�t'`'.as t� e,'agent of the owner -� Registration No Dat .Contractor Mame g OR: No twi the landing. the ab:o� no tie.e, °I hereby apply for 'a pezcn. t as `the. owner o f the °above prop Date Otrner;. .Name Date. ....... 2423 ,,ORT p - TOWN OF NORTH ANDOVER 3? y16 PERMIT FOR GAS INSTALLATION SSACMUSE r This certifies that . . .De.L � c� �!� f. c��. . . . . . . . . . . . . . has permission for gas installation . . . .Y-1-6. . . . . . . . . . . ... . . . . . . . in the buildings of . . . . . . . . . q�7 F . . . . . , . . . . . at .�/31�9. S . t -�. . . . . , North Andover, Mass. Fee. Lic. No.. � �:. . . . . 01/23/97 14:47 15.00 PAID 9GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD:File K MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTINC t (Print or Type) l NORTH ANDOVER Mass. Date --/s=f�� �uilding Location l_�,S— /�Q755 �� Permit # y-L 3 Owners Name J490,J 41 New ;7 Renovation Replacement El Plans Submitted FIXTURES a� N 0! U Z 1L of Q p .Q 0! J « S Cf 0 m 0 �W W {Y t. N Q tt W A (4 aC* tr W z Q us tL' as w `� a 0 a t- z W r z � Z �. W w a o > k N v .f H uusi Z q W C tL' r O Z � O N X d to > C W , Z 4 Q Q .Q O O W O W ti Q z O v cc �• c2 a h- o SUa—ESMT. ! BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR (Print or Type) Check one: Certificate Installing Company Name�,�y l e I 0 Corp. Address ,�);�-- Partner. s;,gyp V-2-.6 Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 1;�:j Other 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 Agent E I hereby certify that all of the details and information t 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 to 'this application w �e_In compliance with all Pertinent provisions of tho Massachusetts State Gas Code and Chapter 142 of the Genual Laws. •. By TYPE LICENSE: Plumber Title Gasfitter humber gnat a of Licensed City/Town: Master or Gasfitter Journeyman 9 APPROVED (OFFICE USE ONLY) Liden5 Number i ! Date.. S . .o/. . . .... . . 4 AORTk �0 f 9 TOWN OF NORTH ANDOVER ! 3 � ' PERMIT FOR GAS INSTALLATION 9 ^' �9SS4CHUSEt This certifies that . . . . . . . . . . . . . . . . . . has permission for gas installation . . '`s..;.-t% . . . . . . . . . . . . . . in the building of�S�. . �f'�.r�" ( . . . . . . . . . . . . . . . . . . . . . . at . . . . . .i , North Andover, Mass. AaFee. . ... . . Lic. No.. . . . ;r "'`. . . . . . . . . . . GAS POR Check# 2- z1 3651 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or T ! JS` - o / , Mass. Date C P it # —3 Building Location �J.� G'ls544U6 Owner's Name O�q7 �, LAS o Alt4 Type of Occupancy New ❑ Renovation ❑ Replace 7 nt 21 P�nss,Submttted: Yes❑ No p (A Y ' N NV `R¢ t- 5 N ¢ N ¢ O O U) = y) W ¢ O 0 m F- J N W � � Z O O r W 4 ¢ O 'O F- ¢ m W < W W 0 — n. C > 4 N ¢ y¢j = V W N W ¢ H W W U) S ¢ Cr Q W W (� ¢ J W > W }. U J Z 4 W J N m Z O 2 O N S y) > ¢ W Z• < ¢ 4 4 O O W O 111 )- ¢ 'Z O n Z v. 0 3 G c7 c� ¢ > o a F- O SUB—BSMT. BASEMENT I ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name �t r'Ae(Z T A • :7-lrn Al A T A�0 Check one: Certificate Address 3 CC�r�C H iv,14 PJ i-fs. ❑ Corporation M E 7'H U E►J 01 rl U 1 k q� ❑ Partnership Buziness Telephone /,z -5 <7-7 1 p-irm/Co. Name of Licensed Plumber or Gas Fitter "'R 0 8 E P-T A- '5A M m t1 A A?q .t. INSURANCE COVERAGE: I have a current pf bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes Ce' No ❑ If you have checked rtes, please indicate the type coverage by checking the appropriate box A 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner❑ Agent [3 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 underthe pe" ed for this application • be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. BY Tof License: C� Plumber4ign'Afuri of Ucbnsed Plu or Gas Fitter retieWtter q33�PMaster License Number City/Town Ujoumeyman