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HomeMy WebLinkAboutMiscellaneous - 1555 TURNPIKE STREET 4/30/2018I N �O rmV -1 O C z 2 m N gmm b m Date ......�//................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING �� � r� U-..-) %,I CJS �alL�This certifies that........................................................................./......................... has permission to perform ......Cr�..�.l/.L�.f wiring in the building of ............. fir. -may.. ......... ..!....................................... at ......� ..../... �c n'. .�. ............................. orth Andover, Mass. Fee .........Cj`�....1!2 Lic. NA/ -z`�� �........ ELEC RICAL INSPECTOR Check # ` ?r7/, 07/30/2014 14:45 17813223173 wilko Systems Inc. #0532 P.002/004 1-NCommonwealthof Massachusetts °��`j'a'�j�'st`°s''V PcmtitNo. //✓1'1 Department of Fire Services ' Occupancy and !•ee Checked i BOARD QF Y1Kt rrR>✓V�lvilOhl R�GUI.ATIO�IS Rev t1071 1 (leave Marti.) , APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perFotmcd in accordance with the �Iassachusetts Electrical Code (MEQ. 527 CMR 12.00 (PLEASE PRATT IN INK OR TYPE ALL INFORMATION) Date: -I- 4-q- I q City or Town of: NORTH ANDOVER To the Inspector o f Wires: P,,u"L M mtl. By this application the undersig eed gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) I — ,j 1 Owner or Tenaut bj j e— L.l Q Telephone No. e►\� Owner's Address S� \\ Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) A � � \J� Purpose of Building Q Utility Authorization No. Existing Service (LO __ Amps 11U Q / 2 O Volts Overhead Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Rork: "t.J Estimated value of Electrical Work; 9DO . r (When required by municipal policy.) Work to Stare - Z S - ( q _ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSU LkNCE COVERAGE: Unlcss 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 cov a is in force, and has cxhibited proof of same to the permit issuing office - CHECK ONE: LNSURANCE [ BOND ❑ OTHER [] (Specify) I Certify, under the pains and penalties of perjury, that the information on this application L true and complete FIRM NAME: if p LIC. NO.: A (Ca 22S Licensee: gr%( 16 byj Signature -.-- j LIC. NO.: ERZ%(ire (Ifapplicoble, engr mpr', in the cense number line. 1, Bus. Tel, No.- 711 _ 322' 3 1`T3 Address. � r�S ® .�°iC t :C42.— cit t oa f Alt. Tel. No.: -iii ( (.40 • �qL `Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License' Lic. No. OWNER'S LN'SUTRANCE WATVER: I am aware that the Licensee floes 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 I,] owner's a ent. Owner/Agent PERMIT FEE: S V r Signature Telephone No. �zt 19, zy-/A/ /30/2014 14:45 17813223173 Wilko Systems Inc. #0532 P.001/004 3 Swains Fund Ave. Rear —-Maldcn. MA 02148 Tel: 781322-3173 EmAii w.kotowski2fa;vcriKg'].1'et www.wilkosysterns.com Facsimile Cover Sheet To: Maura Company: North Andover Bldg. Dept. Phone: Fax: 978-688-9542 From: William Kotowski Company: Wilko Systems, Inc. Voice/Fax: 781322-3173 Date: 07/30/14 Pages including this one: 4 Comments: RB Copy of licenses, workers comp and permit app. 07/30/2014 14:45 17813223173 Wilko Systems Inc. #0532 P.003/004 rage 1U11 Name (Business/Oreanizationllndividual)_ Address:v SaivDS PON4 A v eqR City/State/Zi one r: 781-322.31 Are you an employer? Check the appropriate box: The Commonwealth of Massachusetts 4. ❑ I am a general contractor and I Department of Industrial Accidentstip r ` 5` Office oflnvestigations snip and have no employees ;g 1 Can Street, Suite 100 employees and have workers' CorC irsuranc Boston, MA 02114-3017 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anlicant Information Please Print Lec ibiv Name (Business/Oreanizationllndividual)_ Address:v SaivDS PON4 A v eqR City/State/Zi one r: 781-322.31 Are you an employer? Check the appropriate box: I. Yl am a employer w ith a 4. ❑ I am a general contractor and I employees (full and/or par -time)." have hired the sub -contractors 2. Q 1 am a sole proprietor or panzer- listed on the attached sheet. snip and have no employees These sub -contractors have working for me in any capacity- employees and have workers' CorC irsuranc Type of project (required): 6. �17 New construction. Rernod;.!in,- 8. 71 Demoiit!on ?- L Building addiTion tivo workers comp. tosurance P• . i required.] `j We are a corporation and its , R 10.7,1 Eiec;ricai repairs or additions i 3. ❑ 1 am a homeowner doing all work officers have exercised their 1 ;1.1 Piumbino repairs or additions i fight of exemption cr MGL f j—; Roof repairs myself. (No workers' comp. A P i .i t r c. 15Z 1 4 an w insurance rcquired.l , § (), d e have no � employees. [No worker$' 13. Other ` i comp. insurance required.] } 'A..-ty appiicant that checiks box:11 must aiso fill out the g ;on below showing heir workers' compensation policy infor;nation. Homeowners who submit this af7tdavit indicating they are doing all work and then hire outside contractors must submit anew afidavii indicating such `Convaetors that check finis box must a7uhed an additional sheer Showme the name of the Sub -contractors and !',ate whether or no. those erutres have employees. I`the subs ntraetors have employees, the-, must provide their workers' comp. poi icy number, I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Namc: TA C policy � or Self -ins, Lic. 4: Job Site Address: is—q5 T ration Date: �( CiryiStateiZi. NcnS �L Attach a copy o1 the workers' compensation policy decraration 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 -veer imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up tb S250.00 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 cove, -age verification. I do hereby certify undgr the jaixs and2enaltles of per%urij that the information provided above is true and correct_ -2�- i Phone ". —?1/ - 32 2 —3173 Official use only. Do not write in this area, to be coraplered by city or town official i City or Town: Permit/L.icense # I Issuing Authority (circle one): 1. Board of Health 2, Building Department 3. City/Town Clerk 4. Electrical Inspector Plumbing Inspector 6. Other s Contact Person: phone I: I about:blank 7/30/2014 07/30/2014 14:46 17813223173 Wilko Systems Inc. :0532 P.004/004 'H OF THUS 0.11v, R I C I I SSUES TJE FOLLOWING' S N.4S ER--,ELECTA SYSTEMS ANC. L Alt. t-VItio-fl SKI JR 3 $WA INS "POND A, E, OW, LDIN .4; �i:fhA 021 59158 .::, 6s r . T.& 00 Nix M X ISSUES,THE FOLLOWING" E -'�OIJRHEY ELE I AM, M KOTOW� I J - CT A 3 SWAIISS. POND AVE* o2148-1829' "V .7 59159. STATE OF NEw 'tiAMPSHIRE BUREAU OF ELECTRICALSAFF-TY & UCE"NG NAME: WILLIAM. MXOTOW—SKI 1. 11528 M 2- 3. EXPIRES' 08131/201'5* M. AL � � 17EM /24/2014 THU 10:54 FAX 781 324 4253 Paul T Murphy Insurance /--^ 2001/001 7 1 �53� s KORO® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 7/24/14 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER Paul T. Murphy Insurance A enc 628 Broadway y g Malden, MA 02148 CONTACT Gregory R Porziella -�. PHONE FAX ImpE-MN - (781) 321-9700 A, No: (781) 324-4253 ADDRESS: Greg@ptminsurance.com INSURER(S) AFFORDING COVERAG_ E NAIC fl !NSURERA:SafetV Insurance _ INSURERS:The Hartford $ 2,000,000 INSURED "7 (' Wilko Systems, INC. INSURER C -'-- - - 3 Swains Pond Ave. Rear Malden, MA 02148 INSURER D: AUTOMOBILELIABIUTY ANY AUTO ALLOWN-cDSCHEDULED AUTOS X AUTOS NON -OWNED X HIRED AUTOS X AUTOS INSURER E: ^- INSURER F: 11/9/13 11/9/14 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 C_ON_ DITIO_ NS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — ---- - --. _.._........-...---.--...- ._.... - - --- -_................................_.......... - --..... --....._......._.... ---...... ----................ ...... .... ...... -....._.._...._.__..._.........- IISR ADDL SUER POLICY EFF POLICY EXP L R TYPEOFINSURANCE INSR WVD POLICY NUMBER MIDDY MM/DDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIASIL17Y T CLAIMS MAGE a OCCUR BMA0005974 8/8/13 8/8/14 EACH OCCURRENCE $ 1000 _0_00 `—J DAMAGE TO RENTED S (Ea occurrence $ `100,000 MED EXP one person) $ 10,000 PERSONAL& ADV INJURY _ $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER X1 POLICY PRO- -- LOC _] JECT _ PRODUCTS - ODMP/OPAGG $ 2,000,000 -'-- - - $ — A AUTOMOBILELIABIUTY ANY AUTO ALLOWN-cDSCHEDULED AUTOS X AUTOS NON -OWNED X HIRED AUTOS X AUTOS 1.700742 11/9/13 11/9/14 COMBI deDl�INGLELIMIT $ l OOO OOO BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Peraccident) _. $ A X UMBRELIALIAB EXCESS LIMB }( OCCUR CLAIMS -MADE_ CMU0001371 11/9/13 11/9/14 EACH OCCURRENCE $$ 1,000,000_ AGGREGATE $ 1 , OOO , OOO DED X RETENTION$ 10.000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNER/EXECUTIVE YIN OFFICERM4EMBER EXCLUDED? � (MandatorylnNH) Ups, describe under DYSCRIPTIONOFOPERATIONS betow N/A 08 WEC LB5242 11/14/13 11/14/14 X WCSTATU- OTH- E_L_EACH ACgCENT ------------------- $ 500,000 E.L. IS EASE - EA EMPLOYEE - 5OO 000 E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OP OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Re marks Schedule, If more space Is requl red) Electrician. Policy terms, conditions, and exclusions apply. CERTIFICATE HOLDER CANCELLATION Town of North Andover 1600 Osgood St. North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: Fax: (978) 688-9542 E -Mall: I - 10682 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... !`.^'4-, ........................................ has permission to perform ....... (\ AY plumbing in the buildings of..... Z-.�M ..... .. ..... 5�orth Andover, Mass. at ..... ........f "­­"­'­'­,,' .......... Fee74'9 ...... Lic. No.3./.!3; . ...... . ....................................................... PLUMBING INSPECTOR Check # 5- 15- iw,t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ! CITY 0I _ ---jl MA . DATEPERMIT # JOBSITE ADDRESS Z1 Qn rices 5 OWNER'S NAME lL 1 POWNER ADDRESS TEL T, 8-31--- C)j FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL �f PRINT CLEARLY NEW: RENOVATION: U REPLACEMENT: �]I. PLANS SUBMITTED: YESE11 NOM FIXTURES -1 FLOOR -4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE I DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM f I-_„_ -. I - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER F-7. -- DRINKING FOUNTAIN FOOD DISPOSER ._..-__J _J ___-_.,-(-_--._-, I .-- _. .__.____.I .__..._._-( ._ .__.-._-.1 FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) ___--_..J KITCHEN SINK I J E ( 1 ( I i .__._..__I i d G .._._.__f -J= LAVATORY , POOF DRAIN -SHOWER STALL ERVICE / MOP SINK _ .1 l ( _J __-___1 .-_. _._I __I ------- j __ I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING (. - j ---_.._{ _i ! _ ' _.._..� ( ( i _._. _.1 _i INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES -.- .( NO M ; IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE OF INDEMNITY D BOND P, 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 0 AGENT IQ SIGNATURE OF OWNER OR AGENT 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 compliglice with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 19 PLUMBER'S NAME1�1 1r ii LICENSE # 3 3Z_ I SIGNATURE MP © JP � CORPORATION �JJ #PARTNERSHIPQ# LLC COMPANY NAME ADDRESS y t - CITY e✓C STATE ZIP i'�2 /�S/ TEL '�}� - -2USG _._ nix FAX s CELL m�”` - -.� EMAIL t—'l i'YL-- RON 6i LLI LL The CommonweaM ofMass'aehusetts . 1)e�a�i.�nent of.�nri�cst�rccZAccic�ent� • . Office ofluvestigations 664 Washington Street Roston, MA 42111 vmwasssgovtdza wa-r'k,-,w;0 Vnmtiengatioia. fusurance Affidavit: Sue der sIContractorolFIectr cxansl�Xii Pero Address: loS SC-vue City/State/lip: Ve Vur_ m(A- O -U :�L Phone #:_ Are you an employer? Cb.eck the, appropriate box: Type of project (required.): F 1, ❑ T am a employer with 4, ❑ X am a general contractor and 1 6, []Now construction employees (frill md(ox part time) * conixactors have on. the a t sub -contractors listed on the attached sheef � 7, ❑ E-emodeiing 2. T am a sore proprietor ox PMtaex � ship andlava These sub -contractors have 8. ❑ Demolition. working formeisany capacity, workers'comp. nsurance, 5. ❑ We are a corporation and its g, Building addition [No workers' comp. Jnsuxance o�xcers have exercisad.their 10 ❑ Electrical repairs ox additions required,] 3. ElX am a homeowaex doing all right of exemptionPer MOL 11..❑ Plumbingxepairs or additions myself: Ln workers, comp. c.1.52, §1(4), a- dwehave,n.o 12.❑ Roofxepairs insuranceregaired.]i" employees. [No workers' comm. insurance xectuired.] 1g•❑ Other x.Any applicant that checks box mustalso fill outthesection bel6w showingtheir Workers' compensationpolicy intomiation- i Homeowners who submitibis affidavit 1ndic*gthey 6se doing all.worlg and then hire outside contractors must submit anew affidavit indicating sW6. Untractors that cheAthis box must attached an additional sheetshowingthe name ofthe sub: corftactors andthehworkers' comp. policyinformation. I arm an employer that isproviding lPorXters' compensation insurane fogmy employees Be%tip is zhe policy aracfja i site information. insurance Company Nam Policy ## or Selzins,Lie. #: ExpixatiortDate: lob Site .Address, City/State/Zip: Attach a copy oftheworkers' compenration-policycleclaration page (showing.the policy number and q*atioa date). Failure to secure coverage as xequixedunder Section 25.A ofMGL o.152 can lead to the imposition of ersmsnalpenaltim of a Rize up to $1,500.00 and/or one-year imprisgmant, as well as civil. penalises in the foxxn of a STOP WORD ORDER and a fine ofup to $250.00 a day against the, violator. Be advised that a copy of this statementmaybe, forwardedto the Office of Investigations oEthe DTA for insurance coverage verification. X,10, Berta uridet� tlie_& ns and penalties of,perjury that tlae infomation provid[yeci'above is true /and correct, :'.hone # _+_8 l -- Oficial use oVy. vo not write in dais area, to he completed by city or town official City or Town: I'ermitLTscense Issuing. Authority (circle OR* 1. Board of Health. 2. BuildingDepartment 3. Cifyffm Clerk 4. Electrical Inspector 5. BlumbingIispector f. Other - - - Information aad Instructions- Massachusetts General Laws chapter 152 xeq*es alt employers to provide workers' compensation for their employees. Pnxsuarit to this statute, an eY22, loyee is defined as "...every pexson tri the service of another under any co:dtract ofbire; express orhapiied, oral orwritten..,, An employes is defined as "an individual, partnership, association, corporation or other Legal entity, or anytwo oxmoxe elver engaged in a joint enterprise, and includingthe legalrepresenfatives ofwdeceased employ r .or the redeivex or trustee of as individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore than three apartments and who resides thereto, or the o ccupant ofthe dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or 'It the grounds orbuilding appurtenant thereto shall not because of such employment be doomed 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 op erate a business or to consixuet buildings in the commonwealth .for any applicant who has not produced -acceptable evidence of compliance with, the insurance coverage required." Additionally, MCxL chapter 152, §25C(7) states'Weitherthe commonwealthnor any of its political subdivisions shall enter into any contract for the performance ofpubiie work until acceptable evidence of corn ]lance with the insurance requirements of this chapter have, b con presented to the contracting authority." Applicants Please fill out the workers' comp ensaiion affidavit completely, by checking the b ores that apply to your situation and, if iieceIs*., supply sub-coniractox(s) name (q), address(es) and phonenumber(s) along with their certificate(s) of insurance. LimitedLiabilityCompanies (LLC) or LimitedLiabilttypariaers, i.p (LLl')withn0 employees other than the members orpartners, arenotrequiredto canyworkers' compensation. insurance. SfanLL Cor Updoashave employees, apoJhyisxequired. Be advised thatthis affidavitmay be, submitted to the, Department of Industrial Accidents fox confirmation of insurance coverage. Also be sure to sign and date the affidavit. the affidavit should b e retumad to the city or town that the application for the permit or license is being requested, xrot the Deprar tment of Iindustrial Accidents. Should you have any questions regarding the law or if you are required to obtain, a *orkexs' eompensationpolicy, please call the' Departa mtat thenumber listedbelow: Self insured companies should enteriheir self insurance incense number on the appropriate line. City or Town Officials Pleasebe sure thatthe of xdavit is complete aadpxiated legibly. The Department has provided a space atthe bottom ofthe aiiidavitfoxyouto fill out in the event the Of Rea ofInvestigations has to contactyouregarding the applicant. Please be -sure to f iuthe penUif/license number whichwiil be used as a reference number, In addition, an, applicant t7ratmust submitmultiple pexmit/iicense applications many given year, need only submit one affidavit indicating current policy,informationOfnecessmy)and under "hbMe Address" the applicantshouldwxife "all locations in(city or tOV )" copyo£tlieaffidavitthathasbeen offidallystampedormarked bythecityoxtownmaybepxov------ the applicant as prooftbat a valid of davit•is on lite fox futuxepexmits orlicenses. Anew afCdavitmtist be filled out each year. Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture Q.e. a dog license orpermit to burn, leaves eta.) said person is N'OTxequired to complete this affidavit. The Office of 1'nvestigatfons would like to thank you in advance fox your cooperation and should you have any questions, Please do not hesitate to give us a call. The Department's address, telephone and faxmu nber; Cruozawoaftjx oSasac►uPs DP-Pa-gMG,1 tt QfWU&Ial Accident amoe. oflAwatigoona TQJs 617-7-..Z-49QQ e 406 Qr. 1~877":,11 A Devised 5 Z6 -OS Fax # 61742TW49 1,17 Date. . 1'3� 3482 00' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... ......... has permission to perform ... ........ plumbing in the buildings of ... W Aj at. North Andover, Mass. FeOf '7�Q Lic. No..� . ............... *— PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer -,,;',MASSACHUSETTS UNIFORM APPLICATION TOR PERM IT-:-T0b0VLUM 131 G (Type or Print) NORTH ANDOVER Mass. Date-. Building Location Permit 414. Owners Name New Renovation Replacement Plans Submitted El L; FIXTURES 1 rL STH FLOOR z (Print or Type) Check one: Certifitate;';: Installing Company Name Corp. Q13eQ& \j Address Partner. .,5Y7 arzz�brbxt A)H zo3o 7 Firm/Co. Business Telephone �06 Name of Licensed Plumber: JA�ne,5 Insurance Coverage:Indicate the type of insurance coverage by checking the appropriate box: to 0 z Bond ED' --f -C 4r a: cc ca z 0 Cc 0 ;; !— Ul 5d a: C3 40 ; X 0 a: < cc 0 cc W 0 cc W 4 W - a -C cc 0 -A z = M w. -A X f- ir 3: 0 C1 1-- 4 us gL U. 34 cc W f> > Ir- 0 (n a. U3 0 z 0 v= < X W. < 0 -C I. - Y. 0 0 CA a -j 3; 1.- (a U. a 0 Q SUB—tesvT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TR FLOOR S. 1 rL Insurance Waiver: 1, the undersigned, have been made aware ,that the licensee -of this application' does not hav ny one of the above three insurance coverages. visions By Title 01 AIW -A- n-a-ture of owner/agent of. qp6perty Owner Agent`." cby certify that all of Lite details and infocnia(ion I loave submillcd lot entescd) in alwave application age true and\ rate to the best of eny Lad that al(plunibing work and installations licefornicil under Pctillit i4sucd for this application will be in corospliance with all P911111cpt P60-.4 ie Massachusetts State Plumbing Code and chapter 142 of (lie Gemsat Laws. V12AAI SAnature of Licensed Plumber City/Town: Tvpe Plumbing License APPROVED TOFFICE USE ONLY) ��cense Number ❑ Master Journeyman STH FLOOR (Print or Type) Check one: Certifitate;';: Installing Company Name Corp. Q13eQ& \j Address Partner. .,5Y7 arzz�brbxt A)H zo3o 7 Firm/Co. Business Telephone �06 Name of Licensed Plumber: JA�ne,5 Insurance Coverage:Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M/Other type of indemnity El Bond ED' Insurance Waiver: 1, the undersigned, have been made aware ,that the licensee -of this application' does not hav ny one of the above three insurance coverages. visions By Title 01 AIW -A- n-a-ture of owner/agent of. qp6perty Owner Agent`." cby certify that all of Lite details and infocnia(ion I loave submillcd lot entescd) in alwave application age true and\ rate to the best of eny Lad that al(plunibing work and installations licefornicil under Pctillit i4sucd for this application will be in corospliance with all P911111cpt P60-.4 ie Massachusetts State Plumbing Code and chapter 142 of (lie Gemsat Laws. V12AAI SAnature of Licensed Plumber City/Town: Tvpe Plumbing License APPROVED TOFFICE USE ONLY) ��cense Number ❑ Master Journeyman