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HomeMy WebLinkAboutMiscellaneous - 149 CORTLAND DRIVE 4/30/2018 BUILDING FILE i i i Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that �'.?`.`�?'�y. -! e4-r"•�•- S Q R .o f-.04 . . . has permission to perform ."t U.t`A�. • • • • • • • • • • • • • wiring in the buildin g of . . .6.. . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . `.� •I -L • • • • • • • • • , North Andover, Mass. Fee . . . Lic. No. M. • • �,/� �C.���!, ELECTRICAL INSPECTOR Clueck# ���Z� i •13i' 2 Commonwealth of Massachusetts Official Use only - Department of Fire Services Permit No. I 1 I 4 BOARD OF FIRE PREVENTION REGULATIONS Date Issued: r 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: 1/14/13 City or Town of. North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 149 Cortland Map: Lot: Owner or Tenant Frank Branca Telephone No. 978-685-8538 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Residence Utility Authorization No. Existing Service 200 Amps 120/230 Volts Overhead ❑ Undgrd Z No.of Meters I i I New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Replace meter socket interior/meter man pulled meter&it blew up Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- 1:1o.of Emergency Ig ting rnd. grnd. 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 Initiating Devices No.of Ranges No.of Air Cond. 4 Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other t 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 k'No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Replace meter socket due to National Grid meter replacement Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $400.00 (When required by municipal policy.) , Work to Start: 1/10/13 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 licen- see provides proof of liability insurance including"completed,operation"c verage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the pe it issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Spec' :) I certify,under the pains and penalties of perjury,that the inform on on this a lication is true and complete. FIRM NAME: Andover Electric Services Inc - LIC.NO.: 14302 Licensee: Robert J. Branca Sig tu/nZof LIC.NO.: *.Per M.G.L.c. 147,s. 57-61,security work requires Dep rt P lic Safety"S"License: LIC.NO.: S: (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 978-475-4995 Address: 19 Dale St, Andover, MA Zi): 01810 Alt.Tel.No.: 978-423-8350 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. Permit Fee: $ 55.00 Owner/Agent Signature Phone: II 2 ZI 3 gjam,,4 C-e c ICJ 61 ✓�n c�.�l I l l 2Z�� See 0-4, C�Nie i��c►���cc_. 71 The Commonwealth of Massachusetts 17 Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):Andover Electric Services,Inc. Address:19 Dale St City/State/Zip:Andover, MA 01810 Phone#:978-475-4995 Are you an employer?Check the appropriate box: Type of project(required): 1.F I am a employer with 5 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 New construction 2.❑ 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 [No workers' comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.E] Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:Chartis Policy#or Self-ins.Lic.#:WC 9763814 Expiration Date:4/28/13 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 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. Ido hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Si nature: Date Phone#.978-475-995 Official use only. Do not,write in this area,to be completed by city or town offcial City or Town: PermitfUcense# 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#: Noarp w � CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 657 Q&y 6 20081 Date: March 18, 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 149 Cortland Drive MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Meeting House Common 115 Carter Field Road North Andover MA 01845 J Building Inspector InnC �ORTty '9 own 00 over No. (04Y7 , o1W dover, Mass., O COC MI CMEWICK AERATED PPS\ �y `s BOARD OF HEALTH PERMIT Food/Kitchen Septic System A PECTOR THIS CERTIFIES THAT :..................... - OB 7�__ haspermission to erect.......:;.:............................. buildings on ....................................... :.........................to be occupied as........................:..........:....:............:............... .......::...... .....:....:;:..::......................................................... .5 �.. provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. ou FiaAl/L u / PEPZ.MIT EMPIRES IN 6 MONTHS r( I ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS :..... Service BUILDING INSPECTOR p ©-7 �L Occupancy Permit Required to Occupy Building GAS INSPECTOR Re Display in a Conspicuous Place on the Premises — Do Not Remove F&D No Lathing or Dry Wall 1 o BeDDone FIRE DEPARTMEN Until Inspected and Approved by the Building Inspector. Burner > Street No. /{{ C j j SEE REVERSE SIDE Smoke Det. t��` �'� w i 10RT1� I O+tt�ao a�NO 1 7 -A4TOy APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Buiidina Permit# f S r, ADDRESS/LOCATION OF PROPERTY : 1 yq Co Map 'VC Parcel 2$ Lot Number VA) I T SUBDIVISION DATE REQUESTED FILED/READY FOR INSPECTION 3/1 CLOSING DATE ON PROPERTY: �3%9 FIVE (6) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS$20.00)WILL BE CHARGED IF THE STRUCTURE r DOES NOT MEET ALL APPLICABLE CODES. Permit Issued to: Address SIGNED RO TIN CONSERVATION N PLANNING N DPW-WATER METER 311(Wo SEWER/WATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW Z4 Signature Fife: Application for OC form revised Jan 2007 r �? Date....... `..Z Z..-`.0 ' NORTH °�t"`°;•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSAcNusf� �� This certifies that ................�........;�..................................... ,................... has permission to perform ��� dvS� ............................................................................... wiring in the building of......... ,*".4..A at.......... ��....�`'z ......... ................. . orth Andover,Mass. �» I ........... ..... ...... j dG, f ELECrTRICAL INSPECTOR • 7 Check # j U 8256 Oc, Use Onix o h of Massaehus efts perID,tN andFee�eck� -- ,loawealt. Services occuP�°y k t o f Fire NS ev,.11011 �eaveblan WORK Yv R ],,tnlen NT1ON REGJ�' `ECTR��p�o OF FIRE pR�VE PERF QRM E e(lam 5�� PERIV11T�T0�Sazb se'ltl 1 IA o Wiyes: clow. ORi'accOLd��RM�1T1ON)_ ro the1�P�� aa1 f kdeSOrib�b WoTk�bep Ij�D the el OR pgTg R� tion to p orn� t Tei Phone N°- of T��,n of Ned gives n°tice°f��t.�^'' the tdersign C4 ,pQ�^1C''v r (' roP ateSo%) ,.canon ��ber) ,(�t� ~o (Check�*PP 0 S PP` Sbeet& �'°� — h �L yes No nthor1Za�'°nNo Nietecs O (fl il va- _ $Tenant ( �' er mit'' Utilit9 A °,of ess �'' a b�dmg � �pdasrd❑ No,of 1�e is unction ;C � overhe ad Undid `. \wine 1 Volts pverhead o 'Volts olts I � s f j:0 1 J S6 fires A>nP b the 1 Tumor of achy be waived Y and Amp cal w ork� n .table maY gV A # rs a of Yrop°sedElectri letion o the ollow� N°•° ers A I . ./,star Com Tran orm KV L (p a&Ue) CseII o ato Fans - No. of Ged•'S"sp. me��cY � 1 .fik e5 � 1 Unl es lJotTubs e lu_ Bane No.ofZo�es Luau 0.01 bov d• No.of R��sed ets Npool A d. TVs mon and sire outl swy�nning No.of Devices No.of Lnnof pilgurners �'� Devices sires N°' o{Aier�g NO.of L� ets Gssg' ers .total N°' ef.CoaDevic� eceP Outl ° of Tons0. NO.of R tacle N u.of Air Con& ons Det mho NLS SI No•of Switches get umP N_t �r~ T,ocalC Coanect'on t f Ran$e s T otals• eati�Imo' Securi 0.oSys D or E mvalen Qlirin or E sten No.o Disposers SpacelAx g, aces Da Devices I Wig: t waste 1' i No,of. ,Sh ers 8eatiu �'PP B�sts T.e ecom�g rices-ut E °rva�eIIt i of D• v�'ash 7 N°' N°'°f N° N°•°f DrY ers $i s Totalf the Insp °, No' ector of wires. lcw of ater of Motors as required by N wfie tens desired,ar I �omsssage Satbt"bs Attach addtuirea bytal VI"6" C Rule 10,and uP wor rt issue"nlee s No. Nv enreq the of electrical valent. Th ( � e pTBER' be requested accordancthe P ormaDce it^s sub tial . —`a 'A-wort office ertnit f°t »coverage° swng Value° Elect\riuspectioo the Ovmer,uO Pled operation e to the per", Es Dated �`.\0 16, ,less`Naivedby eluding"comp d roof of s� e complete i yi ork to Stan CO . RAGE: tY insur,�ce in �d has exbibite eify.) an true.N0: ,lam SINCE des proof Of h e is f or (SP app g ovi cove O'fI�R tion on NO: censee PT es bat such BOND at the OfOral ni l,IG the h i ed cert CE s of pet jury, *us.�v�v� Tel.No.* 7 6 ceders v �S0N etre CI CK ONE' the ptuns and p --uc S a e Alt TeL N o, rmel c j cef3'�undue e /� o a�/4'`'t Lic.N e no Y (�5�1 ��S„License: ce coverag er's agent. Ni N �6 " th umber tine.) �!> afetY e�e habilitY�u� O'er e n � t of Public S � owner 1 ecu. t .. ,n t.,in the licens -1�'� es DePa ' ee does not h cbeck one) T,� 0. 1'' r�,LS that the Lrc went 1 the( FEE' " (If aPPlicabie, crit ;ty work req"'r pE alwquv Ad rM G L C. �wA1 ow I �ebY 51-61, �'�atve t� n �V,NER'S Il`ZS B mY sigi1atur Teleph r niredbY law. y -- owner/Agent Si�atur e 1 1 r v 1 1 i 1 fi 1 M y I I ; aPik,, A . ar 64�� tnve,� ��i�►ehLr 20 as eQQtrp N � tI $Pea�8 Bo o�hirtn 4s� 0� e�n•� ��ea �• �0�111- e113'/,S / atOrs/�fe .P' �Att Yoa a4 1�e e yerp - rs e1nplo TnploYer Week the Le°tbl am-a 301 (fall aprop .nd/, app �b0 . o k&rd erreto1 o p tie),* ¢, 11 1 z� a IhJo ung.forme .�mA/oye mer` have��ers/co the 3. j m dN ,conA '�pac;�, 7�'on.thsorbs a4d F Tymractope o f _ lmY jf.(NOrO er do•n ce $all °r ers' mrzc.'toWe 4rL. corn � ee k 6 Necv o fr�trir . `may ns . ri d tcon,,, wO ° ce h orpor8 fi�l eve 8� Q Remodelm 0n t yo�eAAtic$ .. nght aj' have ex and►1s QDemo). r ��,v era boX#f c..j� jxern�Accred h*eir 19. QBmldr Ott d►er� n►irby mastgf$u employ {4),,�d w AjCj O�E diUo �n qn a this bO't �avn Edi h?f° the ern ��L No a hav 1 lao n Info4,y� ' ranre `'pini;rh0n A. the work no !n O� tilrq �pro aheddit� dOingviwghOwia manc�h9L, 12 rrrnbing trs0r8ddibons ice Corn d"�g mor °nstshe s wow it ROCrsdl. 13 Roo fr�pa �Asirs.orsddid oli N ' °°h �, °mr ns ons P e3' ``or Ye' cO�Pe �r�nr°ofd id°hosah°n Pot'y Job Sid Self a Lic #. �°� sw. ,e}O sac bifoir'ft1Oa t Ati h$�o dress Poll�r%°d;cftiag suck e/fie to p3 °rthe moh t seC e0 a � ofup to X 1,500 00 v age compe do fO6' Inv .i- 0. g d8 once undo sQ AoLC'Y d O on D e o r8tio fid° ��ce DIA fO the ho/ oBemen we'llof SGL c. ISAage{sbo �nY/S � Si titre 41,746 lte �Qe coveadv �ia'ed�8 $civij PeiW �n l��eP°I)eY oo�b phos p phi err$c�On eon,°f 's eS rn the rarrn tmPos)tion'Ober er, ent ofa S of X604 de `c fPer�,rr�fr� Y be foiled p pR AEehos a� o Awe cry or To03, D°mot otodie ptcc oil a nRe Iss wl yi.4k& Q6°ye , 1,B04Pd eftec be c°hP! D cO 6 Offer ofHeafth Z @ i rel: � �'1*or�wn o Contang pe P .0c� person meat 3. CItY/T ermticease# o wa Clerk 4 Elee j 'rte laspeckr $ PI '-hone#, ombtng 1 �4r _ �C�O�� �cmpl0yaes• •� 5I °nfOt.t�1e o{bite, �VLSI, comPensa"a any aOn"� an t0 provide-.VO *10T o °*1�undue two or m°t 1 as all emQ�°Yon in tt'e ser" 152 'ur µ ..ovety P �en1+°T BOY yer,�t�e e 1 ;LaWs chap is define as on of� '�le deed amp xev�th Geta. �ptoyec corp° ves°f . emPJOy�•atlt Of%t oust a5sachus5 sem, s�c1a{yon, 1semploymg *05 Occup ellingh ,+ M Su�ttO111ied,° OT astuhlp' ding the 1o$a 1eg�er►t►h' sit1,°t%v OusuahemPlOyet Nessto be °S tmP d «�,indiVe uatrise, arlOri°T aY1d"A'0 ghet blot►Ot ba de `s OC 1 ;s define d in a joint etst►1P� ave.aPat� aei c° loYm anct 1 Ar e'r'pl0y ing Q'�` cl�vid�,Po than` maln 'ffi► o{sib ctaP boil tae oY t}c1e �° of an in vt Ot 11sons t° ll not}Decal enCY shall w��moo�,eaitb or Of tN10 house ha toys P to s1� u a� the co ae require aha11 ening who a there lEO'D4 . io oover4 vls�on5 Te o{a other bu`ldin� Oce b� ce ovfi ingho a too buildu►g apP gLevery to uo to co uso ee w nor snI w *-If dw or the °� 2506)00�opal CO a b�deQ�.of�- 'TDO b aenco o{c° 1 chap 152,�e or permit accePtblc s``1`le lief n1l.acc% orit�! 'resew-Al o{�aho use, vlot p 5 25CC�� f pub1 or %a to yoLv sii� pQ apaa °tia11'J+M n"-t fm ''"vtbeen'?res tbe bo%es that , cert, s�other tt'a�`�a itlta. of the oboete1Y by chi bis)along a v no�t►PldOes hava �q ,ec1 dad�n1p1e d phone nom' atshtps tLl'p�LLC or LLp o{ lnd1 should om aff' �' btlh5'PaT�`eTvce• if an DeP ° 'Che a ffida` ant of ppli�°� a wO mss+ c° s °e� C, 1' �rLc►4�'sa be s bn'� the Oida��pot tha lease fill o ly shb.cot►'�ComPst`ties wows v1t fi eYm sib and nB mqute ast�'to obtain a �t,the o oe�ssary, Liability to his be surro mead ies should Limt +axe not ted Be wised etage pls0 e h os ti if You.axe amd compo Sn of Pte` Tegd too aov fOt t}1a Pa la $alf: on tn% • ow mei' a POlicy 11,ataOn°f- aPFlicafi ons rzpr( ltst�dhal 1 cmPlOr COS OT to ve�Y queste nbct 100100 d a.elty.5h ha dat at ace 2t" �ccide� d you ' . evarp is the D%P lma tovided a ngd1e appU h bnaxora tAivn lr+y+p4 b tha a Prop t ,tec►t� yOure III W. 6160r, �g•cunat►oi Oompanoe t1c nted 1e$►b�'esti '°nsh ice numb ore a�i►davtt Inn i��c�e t self-iceic'tiats lete and Pr ffice Of In used a only subm «all 10 °ns tovided to th, h 1 or'foau dadt is aam4 evert0 0 hich.v,`sllbvcn Yom'n shouldte may be p figed o a Gm c she that'd'ou fill vat t° a Too ons►n ffi`y gv�the�li� the�'°T to davit n'ustbe tne�ial please b &vit for Y the petmttn appKijob Ste padre ed of marked s. A Ito b ine s°s °f the be see t0 fimu iple pt"', A c em o��lll pemya Ot 1nOt elated t°ani frits a 'da any questJons, . pl�u subm� 1f ne 3w*athas S file iDr li wee of 1p t°. 4 d should'you by m on vtt t on policy *'A�y o1 tbst-a alid of �is Ob mid pe ° ' for y°,r coO?a'M 1 tovn%)- asproof owner of leaves mance apPi1 t a hOmot h to VOD ink Y°u'n / Yom' liccnsa would lika to a 4 ves -%St'o. O a call' i er 3SSa uS `� �. c 000f, -0, hasita�to c�,d n n�ae� of A td�ts ,�00 al o d0 r°t t s U4�ss, lcphon The Co o� Dc O"' D� ' at love n Sit 600'`a�lAA 42111 S Bad° 11^ -4900 it 406 OT 1 � �e1,#611-123 F6,, �,govldia Rev' 1 ,1 Date.`��, / NORTq •° .��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that `. . . . . . . . . . . . has permission to perform . . .h. �. . . . �:f�.`.' 'r . . . . . . . . . . . . . . plumbing in the buildings of . . ."i . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . .1.v. �. . �". �. `�. �. .� �. . . . . . . . ... . , North Andover, Mass. Fee. Lu. No. . . . . . . . . . . . . . —� ? / PLUMBING INSPE TOR Check # 7651 1 ? MASSACHUSETTS UNIFORM APPLIC I APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS luilding Location Date ! Owners Name —4 /� j f Permit# Type of Occupancy Amount eS �iu New Renovation rl Rep lacement � Plans Submitted Yes � No ❑ FIXTURES . o a W A a A A t BASEY T ' IST FLDQ2 J 3M FLOCIR �v[ 41HI+Il� SIIi FIJJCIt 6M FIS _ 7IIi ROM SIH FLOCK (Print or type) Check one: Certificate Installing Company Name �! �` Corp. Address dkjf` 2 ❑ Partner. le) ROWO usmess elephone — Firm/Co. Name of Licensed Plumber: („ Insurance Coveraee: Indicate the type of insurance coverage by checking the appropriate box: ji Liability insurance policy [a Other type of indemnity ❑ Bond F1 Insurance Waiver: I,the undersigned,have been made aware that the licensee three insurance of this application does not have any one of the above I Signature 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse State lum ing C=anapter 142 of the General Laws. By lana LU W n ,Ctnc Title Type of Plumbing License l �7 City/Town rcense um er Master Journeyman 1 APPROVED(OFFICE USE ONLY 11uJJ I Date. . }. . ... . NORTH °f TOWN OF NORTH A DOVER - PERMIT FOR GASANSTALLATION Io • s • SACHUSEt This certifies that . . . A. . . . . . . . .`: . . . . .I. . . r;{. . . , , , , , , . „ . „ has permission for gas installation . . . . . `. .'. . . . . . .... ... . . . . . in the buildings of r . .ij . . . . . . . . . . . . . . . . . . . . . at . . / . . . . . ., North Andover, Mass. n Fee. k�L. . . Lic. No./.>.-(,. ?. . . . . . . . . . . . . . . GASINSPECTO Check# / 6543 i MASSACHUSETTS UNN ORM APPUCATON FOR PERMIT TO DO GAS F HING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Loqations Permit Owner's Name J Amount$1 Ci6 New Renovation D Replacement El Plans Submitted ' a U W O OV m F Z1 Oi E. ddF y •r y� GK y F W �r C O O C Z Fw+ Wa z U W �' v� Z F �, p �' > d Z d W Q Z F F w C7 O > cti w U x y oC w > w a z a d ea z o z w o x O d O O x 3 o t7 w o w F [3R B -BASEMENT "'� U � > A a F O SEM ENT I T. FLOOR 1 y D . FLOOR D . FLOOR H . FLOOR H . FLOORH . FLOOR ## 7LALJLOOR. 8TH . FLOOR (Print or type) ff Name Check one: Certificate Installing Company '�- Corp. Address *42 16-4117,0,01— Partner. usmessa ep one Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE I have a current liability.Insurance'policy or it's substantial equivalent. YeSck ons; If you have checked yes,please indicate the type coverage by checking the appropriate box. No� Liability insurance policy Other type of indemnity D Bond D l 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. Signature of Owner or Owner's Agent Check one: Owner 13 Agent 1 hereby certify that all of the details and information I have submitted(or entered) in above application are true an best of m knowledge an d accurate to the Y g d that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S C e d Chap I of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter Title 0 Plumber City/Town,. ❑ as Fitteri spec a Number Master APPROVED F Journeyman i (O FILE USE ONLY) 0