HomeMy WebLinkAboutMiscellaneous - 172 COVENTRY LANE 4/30/20181
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Location
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TOWN OF NORTH ANDOVER
L
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Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL
1
Check #
8556
-Building Inspectpr/
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: ,y DATE ISSUED:
AP A Pe
SIGNATURE: J� `
Building Commissioner/12a=tor of Buildings Date •�
SECTION 1- SITE INFORMATION
1.1 Property Address:
7� CO ve�fr� k&4 c.
1.2 Assessors Map and Parcel Number:
Map Number Parcel Number
Na k/ A d i V t or, IqA d lG Y'J'
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard Side Yard
Rear Yard
R red Provide RegWred Provided
RegWred Provided
1.7 water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information:
Public` ❑ Private ❑ Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System
Municipal 0 On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
1
11
2.1 Owner of Record
le h'n 110 � U Co ✓Cn
Name (Print) Address for �Service: /
77F GFGd 0Y� /V, 4ndoVe.•-
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Si atuco'# Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Lice `sed Construction Supervisor:
Licensed Construction Supervisor:
Address
Signature Telephone
Not Applicable ❑
License Number
Expiration Date
3.2 Registered Home Contractor[ r /
-Nyi U C ailn't01? a ua&i ✓/OS/I2S /� �'
Not Applicable ❑
�/ q
Company Name �/ �/%
x00 SL) #&oZZ(� N4✓7�* /`r1)�[0�/(a✓
Registration Number
13 J Y*"
Si nature Telephone
Expiration Date
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑
Accessory Bldg. ❑ I Demolition ❑ 1 Other ❑ Specify
Brief Description of Proposed Work: ,r
Y/iIL�Z ..;F/ all 9
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
/ 4 Q'
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (a) X (b)
a,y
�- r
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
9'10.
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building pen -nit application.
Signature of Owner Date
SECTION 7b /OWNER/AUTHORIZEDU�THORIZED AGENT DECLARATION
I, :3 i ✓/ 4 43A J /0 a' e- as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
vid C:& I7-n'l ate.
64 .�.'
Owner/Aeent
g11 mss'
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
tl�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
d 600 Washington Street
Boston, MA 02111
°�M SV•�• www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiorOndividual):j%L.F—KNI
Address:_ ��� �0 UAV 7"R J LAI
City/State/Zip: b, AN D 6 U= 84,1 Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet" I
ship and have no employees These sub -contractors have
working for me in any capacity. workers' comp. insurance.
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
3. ❑ I am a homeowner doing all work right of exemption per MGL
myself. [No workers' comp. C. 152, § 1(4), and we have no
insurance required.] t employees. [No workers'
COMP. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11. F-1 Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # 1 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
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: �• „y�.
Policy # or Self -ins. Lic. #: Vwd L OQ W001 z0 Expiration Date: gla,3 20's—
Job Site Address: 19 & V4464e J 4041-L City/State/Zip:_A%�i%hl/GVei e/Oj"'
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 mYprisonment, 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 underrthe pains andpenalties ofperjury that the information provided above is true and correct
Phone #: 7 % G (p 0 3� 1/0?0
Oficial use only. Do not write in this area, to be completed by city or town official:
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health L Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
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 ab 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 number 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 I(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
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
DAVID CASTRICONE
ROOFING, SIDING & REMODELING REPLACEMENT ME IMPROVEMENT CONTRACTOR REGISTRATION NUMBER 104569 AUG WIND#ES& 'WTI
HO
200 SUTTON STREET, SUITE 226, NO. ANDOVER, MA 01845 24
7 HILLSIDE ROAD, BOXFORD, MA 01921 B y
In North Andover 978-683-3420 In Boxford 978-887-6147 . .............
In Haverhill 978-374-7314
Uwe the owner(s) of the premises mentioned below, hereby contract with and authorize you as contractor, to furnish all necessary
materials, labor and workmanship, to install, construct and place the improvements according to the following specifications, terms and
conditions, on premises below described:
Owner's Name............ Lll/
AL ................................ Tel one #...... 1,11.6 .... . ...
Job Address ...... eX41–
._411 .4%.e . ....... city .... N,0 ./...1' t? .................. State .... MA .........
x
Specifications:
...... ........ ........ ......................................
Y/Apply ... vinyl siding* 'a"nd' ... corners. ... Type: .01–
.........................................................................................................................................................................................
z.,Cover fascia boards and rake boards. -Irastall vinyl soffit - solid /JRro_r5–M1>
........... ......................................................
to over wood casings around �wa�iaws.Replace any gable vents w i t*
-P4?.QZ.1 ............... .....................................................................................................................
Areas t be
covered: .......... A/L..S. D .
0-4-� ............ .. ............ . -V-/_A_tA . ..................................
'
............ . . . ....... 1. ^S.. r- / J........etr ... sr
...........
OF �
..................................
..........
...... ....... ..... ............... ............ / ...............................................
"F ..... ..............................
................
.............. ........................................................................................................ ....................... . . .......................................
....................................................
..................................
QT .................................................
.................. Y. . .....
One Year Workmanship War&&UtkJNQransferabIe) ........................ .............. ........
ManufacturerI Warr: arr: -f?as S eciried y maiii%�turcr
and d Labor to 1:tPayable .....�.,r,00 ........ on ........ ... .......
Payable ................ ......... Balance payable on completion of job
Owner or Owners are not responsible for Property Damage or Liability while job is in operation.
Contractor is not responsible for any damage to the interior of property, including pre-existing conditions (i.e. water stains, crumbling plaster, exposed nails) or
conditions resulting from application of materials specified above. (i.e. objects coming loose from walls, crumbling plaster, exposed nails, dust in attic or other living
spaces, water stains when roofing shingles have not had adequate time to cure).
Upon completion of above work all undersigned agree to execute and deliver to contractor, their joint note in accordance with his (their) above obligation as requested
by contractor. Upon refusal to do so, contractor may at its option declare the entire contract price or so much as then remains unpaid, immediately du and payable. It
is agreed that, if permitted by law, contractor shall be paid by the owner(s) all reasonable costs, attorney fees and expenses, in addition to the amount due and unpaid,
that shall be incurred in enforcing the terms and conditions of the contract and/or any lien in connection herewith.
It is further agreed that this contract may be assigned by contractor, and also that the obligations hereof shall bind and apply to their heirs, successors or estates.
The undersigned warrant(s) that he is (they are) the owners(s) of the above mentioned premises and that legal title thereto stands of record in his (their) names(s).
There are no representations, guaranties or warranties, except such as may be herein incorporated, if any, nor any agreements collateral hereto, nor is the contract
dependent upon or subject to any conditions not herein stated. Any subsequent agreement in reference hereto shall be binding only if in writing and signed by all
parties
All Home Improvement Contractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to:
Director, Home Improvement Contractor Registration
One Ashburton Place
Room 1301, Boston, MA 02108 Tel: 617-727-8598
Any and all necessary construction -related permits shall be obtained by the Contractor. Any Owner who secures his own construction -related permit or deals with
unregistered contractors shall be excluded from access to the Guarantee Fund.
Approximate starting date of work....
........... Completion date...........
Receipt of a copy of this contract is hereby acknowledged, and it is further acknowledged by the undersigned that the foregoing
provisions have been read and the contents thereof understood and that no representation or agreement not herein contained shall be
binding upon the parties and that all of the agreements and understandings of said parties are contained herein.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
Owner has three business days to cancel this contract and incur no penalty.
IN WITNESS WHEREOF, the parties have hereunto signed their names this ........�Z? .J ... day of - - I %, � I .... r—
IN
Signed
................................. . .................................................. Owner
............. r ..................................................................... Owner
Per.......................................................................
Representative
NORTH ANDOVER BUILDING DEPARTMENT
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
at: is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c 11, S 150 A.
Also, note Permits are required under Fire Prevention laws Chapter 148 Section
10A.
The debris will be disposed of in:
v9w� -ro
/ 72
(Location of Facility)
Fire Department Sign off:
Dumpster Permit
R -
Signature of Permit Applicant
oS,-
Date
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3 �r 6 Date . S . ...... G. (! ..... .
NpaTM TOWN OF NORTH ANDOVER
pb` ao .e 1�0
p PERMIT FOR GAS INSTALLATION
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This certifies that x '.-� .................
has permission for gas installation . .. ..... ..`.. ........... .
in the buildings of .............................
at ../.7. >.... c. .......4� ...... ,.North Andover, Mass.
Fee—A. C,.—: Lic. No.. �
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
jMASSACHUSETTS UNIFORM APPLICATOR FOR PERMIT TO DO GAS FITTING
or print) O
p � Date �/5 19 �
NORTH ANDOVER, MASSACHUSETTS
Building Locations �U V'�/t'+-'J K Permit #
Amount S J^
Owner's Name / -! 4 i' P4
New Renovation ❑ Replacement ❑ - Plans Submitted ❑
(Print or type) Check one: Certificate Installing Company
Name je � l�--C 104' kf ❑ Corp.
Address 66
9r
❑ Partner.
Business Telephone 1r, Kb —t) L-1 Firm/Co.
Name of Licensed Plumber or Gas Fitter r� (� `� ,�1A rer ,. , -e,
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ NO
If you have checkedyes. please indicate the type coverage by checking the appropriate box.
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 1=42 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
best of my knowledge and that all plumbing work and i a
compliance with all pertinent provisions or -the Massabis,61
By:
Title
C ityiTown
I ADPROVED (OFFICE. USE ONLY)Fu 1
fitted or entered) in above application are true and accurate to the
s ormed under Permit Is ed tort application will be in
to gas Code of Chapte I t eneral Laws.
Signature of 1
Plumber
❑ Gas Fitter
�Iaster
❑ Journeyman
Sed Plumber Or Gas Fitter
icense I um—oer
IN2 15 31 Date....r
0 t"'° '..
0 TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that........ C.: ....... ....................
has permission to perform ... T-�^ ...........................
wiring in the building of ...... tw.c,..., .. ...........................................
at.. ) q. 9 ..... ...... ��k) ..................... orVthdo r, ass.
Fee ..... 3 .!)J-- Li 1/
c. No.. ji!�: ... ................
...........
...........
LECTRICAL INSPECTOR
C� W � � 1()4/27/99 13:24 35-00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
O:ftce Use O"Ir / �
The Commonwealth of Massachus lam''
Pv.tt :co.
Department of Public Safety
Occupancy i Fee owckee
BOARD OF FIRE PREVENTION REGULATIONS SV CMR 1200 3/90 (lean blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All wwk to be performed In accordance with the Maccachuscru Electrical Code. 521 CMR 12:00 p
(PLEASE PRINT IN INK OR TYPE ALL INFORM&TION) Date y-3
—.5
City or Town of «1 f 4"+ 60('70-rk. To the Inspector of Wires.
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number) / of 1 17 C% 497f -F /
Owner or
Owner's Address
Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
'teN� Service Amps / Volts Overhead ❑ Undgrd ❑ No: of ikters
Number of Feeders and Ampacity �.._
at 'i* and Nature of Proposed Electrical Work ._1--�ci ar9.�r-A- -) AUJ
No. of Lighting Outlets
No. of Hot Tubs
No. of Transformers Total
INA
No. of Lighting Fixtures
Swimmin Pool Above In-
8 grnd. ❑ grnd. El
w
,RVA
No. of Receptacle Outlets
No. of Oil Burners
Battef Emergency Lighting
Units
No. of Switch Outlets
No. of Gas Burners
FIRE ALARMS • No. of Zones
No. of Detection and
Initiating Devices
No. of Sounding Devices
No. of Self Contained
Detection/Sounding Devices
Local Municipal ❑Other..__ M�~
Connection
No. of Ranges
8
Total
No. of Air Cond. tons
No. of Disposals
No. of pumps Total Total Tons KW
No. of Dishwashers
Space/Area Heating KW
No. of Dryers
Heating Devices KW
of Water Heaters KW
No, of No. of
Sirns Ballasts
Low Voltage'-
Wirine
No. Hydro Massage Tubs
No. of Motors Total HP
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws y
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial
equivalent. YES ❑ NO 0 I have submitted valid proof of same to this office. YES ❑ NO ❑
If you have ch ked YES, please indicate the type of coverage by checking the appropriate box.
INSURANCE rND ❑ OTHER ❑ (Please Specify)
,C� (Expiration ate
�
Estimated Value o Electrical Work $/-2 r C-3�� ` G ���
Work to Start _-2 " Inspection Date Requested: Rough Final i,
_Z
Signed under the penalties of perjury:
FIRM NAME LIC. NO.
Signatuz LIC. NO.
� r
Address
Q' -- l^ �. Bus. Tel. No. 7
Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee doe avetthe insurance coverage or is sub-
stantial equivalent -as required by Massachusetts General ws, and that ay signature on this permit 1
application waives this requirement. Owner Agent (Please check one) /�)� U
J d
Telephone No. PERMIT FEES /V/
q 1
Location
No.' O 4//t—)/
9`c
Date
NORT1y
TOWN OF NORTH ANDOVER
*
Certificate of Occupancy $
+
Building/Frame Permit Fee $
ss�CNusE��
Foundation Permit Fee $
Other Permit Fee F001 $_
It
Sewer Connection Fee $
Water Connection Fee $
4k
TOTAL $
(� f
Building Inspector
04/08/99 09.34 169.00 PAID Div. Public Works
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Date..?.....�.............
TOWN OF NORTH ANDOVER p
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PERMIT FOR GAS INSTALLATION
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This certifies that ...1... ..... . . . . ..................... .
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has permission for gas installation .....................
in the buildings of :...........:...........................
at .................................... . North Andover, Mass.
Fee. f....... Lic. No........... ...... (..... ..
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Viinl Ir Type) -�
d A - Mass. Date 19 Permit tt 3 l
Building Location ?'L joo✓e0 J')@ p�43 Owner's Name p ' )q2,6 KAJl A
- AJ YJOVLi2.
Type of Occupancy_
IN
New ❑ Renovallon g Replacement ❑ Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMOANY Check one: Certificate #
Address 55 MARSTON ST. CJ Corporallon 102
LAWRENCE, MA. 01840 ❑ Partnership
Business Telephone (978) 687-1105
O Firm/Co.
Name of Licensed Plumber or Gas Filter FRANCIS X. CORKERY
INSURANCE COVERAGE:
have a current liability 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 ItabllHy Insurance policy (9 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. Genual laws%and that my signature on this permit application waives this requirement.
Check one:
OwnerQ Agent 0
Signature of Owner or Cis Agent
1 hereby certify that all of the details and Inlormalion 1 have submitted (or entered) In above application are true and aacurale to the best of my
knowledge and that all plumbing work and Installations performed under Ilia permit Issued for this application will b n co (lance with art provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Ge oral laws.
Type of Ucense: r
Title Plumber CSWAdie of UcensedPlumber or Gas it
Gaslitlor 3745
Master Ucense Number
City/Town Journeyman
INNAM
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Installing Company Name BAY STATE GAS COMOANY Check one: Certificate #
Address 55 MARSTON ST. CJ Corporallon 102
LAWRENCE, MA. 01840 ❑ Partnership
Business Telephone (978) 687-1105
O Firm/Co.
Name of Licensed Plumber or Gas Filter FRANCIS X. CORKERY
INSURANCE COVERAGE:
have a current liability 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 ItabllHy Insurance policy (9 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. Genual laws%and that my signature on this permit application waives this requirement.
Check one:
OwnerQ Agent 0
Signature of Owner or Cis Agent
1 hereby certify that all of the details and Inlormalion 1 have submitted (or entered) In above application are true and aacurale to the best of my
knowledge and that all plumbing work and Installations performed under Ilia permit Issued for this application will b n co (lance with art provisions of the Massachusetts Stale Gas Code and Chapter 142 of the Ge oral laws.
Type of Ucense: r
Title Plumber CSWAdie of UcensedPlumber or Gas it
Gaslitlor 3745
Master Ucense Number
City/Town Journeyman
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