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MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(6171723.3800 Ma Only (800)392.6108. FAX (800)851-8424
6/8/2006
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.36 F-RE-CEIVED
Claim has been made involving loss, damage or destruction of the above captioned propert, 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
I
JUN 12 2006
NORTH ANDOVER HEALTH DEPT.
TOWN of NORTH ANDOVER
HEALTH DEPARTME
NORTH ANDOVER TOWN
HALL
------ NT
NORTH ANDOVER MA
01845
Re: Insured:
ADELINE VENTRILLO & RICHARD VENTRILLO
Property Address:
14 WOOD AVE, NORTH ANDOVER, MA 01845
Policy Number:
0853971
Type Loss:
Water Damage
Date of Loss:
06/06/2006
Claim Number:
230878
Claim has been made involving loss, damage or destruction of the above captioned propert, 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
I
NORT1,
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��SSACONUS�
Date.../ ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that..:.........0..!-� P.�.........................................................
has permission to perform ..........................................
wiring in the building of�4-'A— w ..........................................................
at .. Z.`I.....I O-e�......S............................. .. . North Andover, Mass.
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Fee'�............. Lic. NoQ5✓. F..............
ELECTAI&IINs /
Check #
8560
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Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and FeeChecked'�G�
[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 W INK OR TYPE ALL INFORMATION) Date:-/ ` I to—,6 9
City or Town of. NORTH ANDOVER
To .the Inspector of Wires:
By this application the undersigned j�g/iives'n`ot'ice of hi or her intention to To
the electrical work described below.
Location (Street & Number) `'f— W o d A o -k
Owner or Tenant a6 s-e-p� -TRIC kdQ, r T.1 h
Owner's Address
S
i�
e ep one No.
Is this permit in conjunction with a b ding permit? Yes No
Purpose of Building��S i b -2..Y) - a � 11 (Check Appropriate Box)
Utility Authorization No.
Existing Service 00 Amps U / SZU Volts Overhead L =J d r
Undg f
❑ No. of Meters
New Service Amps / Volts Overhead
❑ Undgrd ❑ No. of Meters
Number of Feeders and. Ampacity
Location and Nature of Proposed Electrical Work:
Y2. 1A,5w.1n-tyl Q`r)
No. of Recessed Luminaires Q
Com letion of the folio
No. of Ceil: Susp. (Paddle) Fans
table may be waived b the Inspector
No. u, Total
No. of Luminaire Outlets
No. of Hot Tubs
Transformers,
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ In- ❑
o. o mergency Ig g
No. of Receptacle Outlets 1 Q
d. rnd.
No. of Oil Burners
Batte Units
FIRE ALARMS No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
No. of Ranges
No. of Air Cond. Total
Initia ing Devices
Tons
No. of Alerting Devices
Na. of Waste Disposers
Heat Pump Number Tons KW
Totals: .. `
o. of Self -Contained
No. of Dishwashers
Space/Area Heating KW
Detection/Alerting Devices
Local ❑ Municipal
No. of Dryers
Heating Appliances K,
Connection ❑Other
Security Systems:* _
No. of WaterNo.
Heaters I{R'
of o.
No. of Devices or Equivalent
Si s Ballasts
Data Wiring:
No. Hydromassage Bathtubs
No. of Motors Total Hp
No. of Devices or Equivalent
Telecommunications Wiring:
OTHER:
No. of Devices or E uivalent
Wires.
Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) 'Z(j � C
I certify, under the ains and penal 'es Qf�[erjury, that the information on this application is true and complete.
FIRM NAME: O q 1 1 TC(, �-L,
Licensee: rj K M� Q S N 6 ova LIC. NO.: L� 3_ _
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Pr><nt Le�bly
Name (Business/Organization/individual):
Address:
City/.State/Zip:
Phone #: .
Are you an employer? Cheek.tbe appropriate box:
The Commonwealth of Massachusetts
k i
Department of Industrial Accidents
Office of Investigations
have hired the sub -contractors
listed #
partner-
on the attached sheet
600 ffrashington Street
These subcontractors have
Boston, MA 02111
t t WWW.HZass.govIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Pr><nt Le�bly
Name (Business/Organization/individual):
Address:
City/.State/Zip:
Phone #: .
Are you an employer? Cheek.tbe appropriate box:
I. ❑ I am a employer with
4, ❑ 1 am a general contractor and I
employees (full and/or part-time),*
2. [] I am asole proprietor or
have hired the sub -contractors
listed #
partner-
on the attached sheet
ship and have no employees
These subcontractors have
working for mein any capacity,
[Na workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No•workers' comp,
c, 1.52, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. [] New construction
7. Q Remodeling
S. Q Demolition
9. ❑ Building addition
10. Q Electrical repair; or additions
11.[] Plumbing repairs or additions
12T� Roof repairs
13. [1 Other
--- - — --i luso nu our tae 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.
tCorttractors that check this box most attached an additional sheer showi the name of the sub -contractors. and their worker' comp. policy information.
I
am an employer that is provtding:warkers' compensation cnsuraneefor nty. enrpinyees
information Below is the policy and job site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address; City/State/Zip:
Attach a copy of the workers' comrpensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenaldes ofperjury that the information provided above is true and correct
Si tune:
Date:
Phone #:
thew use only. Do not write in this area, to he 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 #:
0
Information and Instructions c
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 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
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 nw nber. 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 bum 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations s'
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax # 617-727-774
www.mass.gov(dia
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
Nnt or Type) /AOn
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Mass. Date 19 Permit # 37
Building Location Owner's Nami i ( 8
I
lrutatling Company
Business T
Type of Occupancy
New p Renovation O Replacement/ Plans Submitted: Yes ❑
NQS
FIXTURES
Name of Licensed Plumber
I
Check one:
- 'Corporation
❑ Partnership
❑ Firm/Co.
Certificate
rA 0 g
INSURANCE COVERAGE:
1 have a current_Jlabgfty insurance policy or its substantial q
Yes No ❑ equivalent which meets the requirements of MGL Ch. 142.
If you have checked rimes, Please Indicate the
type coverage by checking the appropriate box.
A liability insurance policy
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 appgcatlon waives this requlremeht.
Check one:
of Owner or Owner's Agent Owner C1Agent ❑
1 hereby certify that all of the details and information I have submitted (or entered) in above a
knowiedge and. pplication are true and accurate to the best of my
that all plumbing work and installations performed under the rmit issued for this application will be in compliance with all
Pertinent provisions of the Massachusetts State PI ng Code and Chapter Z of the General Laws.
Title Jv gnatu� f cen um r A
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NORTH
TOWN OF NORTH ANDOVER
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PERMIT FOR PLUMBING
34C US
This certifies that ........
has permission to perform .................
plumbing in the buildings of ";.k ...........
at. . ............. North Andover, Mass.
3-�
Fee.—,.-.. . Lic. No .......... ....... . `.E.) , -
Um BING INSPECTOR
06/12/97 16:11 35.04 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMEIING
(Print or Type)
Andover-, Mass. Date 19_2j Peffn t# J J f
Building Location (/(/rdOef L/e Owner's Name P0r('116
r
Type of Occupancy fs
New .t2"' Renovation ❑ Replacement O Plans Submitted: Yes ❑
- •, No,.L-
SUR—gSMT.
BASEMENT
AST FLOOR
2ND FLOOR
3RD FLOOR
ATH FLOOR
STH FLOOR
6TH FLOOR
TTH'F_L.00R
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Jas'taliing Company N,
Address q 6 l
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Business Teleohonp �
Name of Licensed Plumber
FIXTURES
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Check one:
-O'Corporation
❑ Partnership
O Firm/Co.
Certificate
�Og
INSURANCE COVERAGE:
I have a current aNo ❑
bility Insurance policy or Its substantial equivalent which meets th
YesNo requirements of MGL Ch. 142.
If you have checked yes, please Indicate the type coverage by checkin the
9 appropriate box.
A liability insurance policy Other tvnP „t
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 h9ent Owner O 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
pertinent provisions of the Massachusetts State Pl�gnature
mbing Code and Chapter 14 of the/General Lawspir�tion will be in compliance with all
By MAY 1 4 iZ)ZYCCS r
Title of m r
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Check one:
-O'Corporation
❑ Partnership
O Firm/Co.
Certificate
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INSURANCE COVERAGE:
I have a current aNo ❑
bility Insurance policy or Its substantial equivalent which meets th
YesNo requirements of MGL Ch. 142.
If you have checked yes, please Indicate the type coverage by checkin the
9 appropriate box.
A liability insurance policy Other tvnP „t
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 h9ent Owner O 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
pertinent provisions of the Massachusetts State Pl�gnature
mbing Code and Chapter 14 of the/General Lawspir�tion will be in compliance with all
By MAY 1 4 iZ)ZYCCS r
Title of m r
QtyfTown Type of Ucen . Mast .fournAVMAn -�r'
ti.
Date
±. 3339
r10RTM
oro;t",;•.',�oo� TOWN OF NORTH ANDOVER
MOM
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'° PERMIT FOR PLUMBING
'SSA�MUS�
This certifies that, .......... .
has permission to perform . bv.44t--.7. ..................
plumbing in the buildings of I..
at ... ....... ... , North Andover, Mass.
Fee. c? �7 `... Lie. No.. 1P41 s... ........ z . 't'vY"'
i PLUMBING INSPECTOR
05/16/97 09:05 28.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Typ )
►��nc�aver l
Mass. Date � l L .19 Permit # J
Building Location
19 wood 'J �e Owner's Name V P;4 r" //d
'yy Type of Occupancy '
G
Installing Company
New 0'__ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No C j
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t o PS c' 2 k OA O C 8'3 ..
Business Telephon 206 —Tf;-7- ; - 2 _5-S'8r
Name of Licensed Plumber or Gas Fitter G I`c t
Check one:
Corporation
❑ Partnership
❑ Firm/Co.
Certificate
'D.o 9
INSURANCE COVERAGE:
I have a current bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes. please indicate the type coverage by checking the appropriate box.
A liability insurance policyla__� 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 ❑
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 be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen laws.
By lorfne
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Name of Licensed Plumber or Gas Fitter G I`c t
Check one:
Corporation
❑ Partnership
❑ Firm/Co.
Certificate
'D.o 9
INSURANCE COVERAGE:
I have a current bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes. please indicate the type coverage by checking the appropriate box.
A liability insurance policyla__� 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 ❑
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 be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen laws.
By lorfne
fUcense:7i11e MA lyy I mber Signature of nse Plum er r G FitterSitterCity/Town ser License Nu er �C)APPFVFn rnFf irF i icG nnn v yman
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12; a 2536 Date ... .b �9..7........
,pRrti - TOWN OF NORTH ANDOVER
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PERMIT FOR GAS INSTALLATION
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This certifies that kevdo'�7F/. . , ���,� , , , , , , , , , , ,
has permission for gas installation. w �: -�L° . !
in the buildings of .1/99 � :61 ('l. ( .........................
at ..../ X.Y.:e ....... rth Andover, Mass.
F Lic. No./U4 ).. 7.. � . �. ..........
/ /� 09'05 28.00 PAID GAS INSPECTOR"
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
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pf NORTH
p s
a
�7S SAC MusE�<
Date ... d.... ....... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ...:6. ... ....�"�.�`` �...../... .
has permission for gas installation ............
in the buildings of .... . fir...fid.......................
at ./y �Jih.. .. .......... North Andover, Mass.
Fee.e: .. Lic. No. I,33S;... ��,Pki�C
, �...........
'GAS I
Check # ��
6334
MASSACHUSETTS UNDURM APPUCATON FOR PERMPT TO DO GAS FrMNG
(Type or print) Date Z% z Z/ Q 8
NORTH ANDOVER, MASSACHUSETTS `
Building Locations ;` % 11V0.1 a, AIC -
Owner's Name
New ❑ Renovation ❑ Replacement ❑
G
SUB-BASEMI
BASEM ENT
IST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
BT H. FLOOR
Permit # 33 _
Amount $
,4ti1 (_ 0 5 (D
Plans Submitted ❑ . "
r� w a o
a u z
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�a o x 3 0
(Print or type)11 ii. j� 01
Name_ ,i a*C1Ij `Y11VM%�-'i`.j- A� .1 0J(
Check
L.ne: Certificate Installing Company
J orp'
❑ Partner.
❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter r r r --i-5
FINSURANCE COVERAGE Check one:
e a current liability insurance• policy or it's substantial equivalent. Yes ❑u have checked es lease indicate the No❑
Y, P type coverage by checking the appropriate box.
lity 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 wner ❑ Agent ❑
1 hereby certify that all of the details and information 1 have submittee or a red) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatio pe rf ed u9*!.aeifnit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts t Co to
a r- the General Laws.
By:
Title
City/Town,
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber
❑ Gas -Fitter (cense Number
aster
❑ Journeyman
zw
p
'
F
Check
L.ne: Certificate Installing Company
J orp'
❑ Partner.
❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter r r r --i-5
FINSURANCE COVERAGE Check one:
e a current liability insurance• policy or it's substantial equivalent. Yes ❑u have checked es lease indicate the No❑
Y, P type coverage by checking the appropriate box.
lity 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 wner ❑ Agent ❑
1 hereby certify that all of the details and information 1 have submittee or a red) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installatio pe rf ed u9*!.aeifnit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts t Co to
a r- the General Laws.
By:
Title
City/Town,
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber
❑ Gas -Fitter (cense Number
aster
❑ Journeyman
O' NORTN 1MC
ti 9
46
.�_
Date. '..........
TOWN /NORTH ANDOVER
PERMIT FOR PLUMBING
US
This certifies that ....... ..... r�.�..... .1. ........... ... .
has permission to perform ........ .........................
plumbing in the buildings of ..................................
at. `.... L...`...?... ...,�.,......� North 'Andover, Mass.
1.3��
Fee ......... Lic. No.......... f/'�G.................
PLUMBING INSPECTOR
Check p
7659
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location t,J o ON A UE Owners Name � �0.tJJ r, coc4,(,(,o Permitit
Amount
Type of Occupancy
New ri Renovation M Replacement Plans Submitted Yes No10
(Print or type)v i Check one: Certificate
Installing Company NameZ %S ! U � Corp.
kj
a Address 4-qk' n /4 t.) Partner.
Business Telephone 7� �,�� 7� 73 Firm/Co.
Name of Licensed Plumber: p it �— < r i
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I h e mi ed (or en d) in above application are true and accurate to the
best of my knowledge and that all plumbing work and ' t ati s pe under Pe irl` sued for this application will be in
compliance with all pertinent provisions of the Mas and Chapter 142 of the General Laws.
By 1g UkSUlf Eicensecum er
Title
Type of Plumbing License
x.73 ��
City/Town icense um er Master Journeyman ❑
APPRO VED cor�lcE USE ONLY
J
i
Er', =%0 0M11MMMMMMMMMMMMMMMMM=M=MMMMM
i y o g_c;
nnnnmmmmmmmmmmmmmmmrmmmmm
MMMMMMMMMMMMMMMMMMMMMWMM
W111-1011-1:
MMMMMMMMMMMMMMMMMMMMMMMM
i or.•
mmmmmmmmmmmmmmmmmmmmmmmm
f#:•
mmmmmMMMMMMMMMMMMMMMMMMMME
=•
MMMMMMMMMMMMMMMMMMMMMMMMMN
(Print or type)v i Check one: Certificate
Installing Company NameZ %S ! U � Corp.
kj
a Address 4-qk' n /4 t.) Partner.
Business Telephone 7� �,�� 7� 73 Firm/Co.
Name of Licensed Plumber: p it �— < r i
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I h e mi ed (or en d) in above application are true and accurate to the
best of my knowledge and that all plumbing work and ' t ati s pe under Pe irl` sued for this application will be in
compliance with all pertinent provisions of the Mas and Chapter 142 of the General Laws.
By 1g UkSUlf Eicensecum er
Title
Type of Plumbing License
x.73 ��
City/Town icense um er Master Journeyman ❑
APPRO VED cor�lcE USE ONLY