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HomeMy WebLinkAboutMiscellaneous - 176 MIDDLESEX STREET 4/30/2018 (2)N Date. ,� ...`.. G 2 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . f� �z;'.��' r < 6e 1,} ��� has permission to perform .....��'!-s .� -.e: ................. plumbing in the buildings of ... at . I ?.("... A/!.'.=ICl/' s Fee. ?J. Lic. No—// i � .'. Check # S ',) C 5084 ..................... . ........ North Andover, Mass. PLUMBING INSPECTOR } r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) J NORTH ANDOVER, MASSACHUSETTS Building Location 1 `) (P New © Renovation )wners Name of Occupancy i,,LS I Permit # Amount Replacement 1:1 Plans Submitted Yes 0 No FIXT'IRES -►,�nnnnnnnnnnnnnnnnnnnnnnnnnn ' � nnnnnnnnnnnnnnnnnnnnnnnnn �,« nnnnnnnnnnnnnnnnnnnnnnnnn ��«nnnnnnnnnnnnnnnnnnnnnnnnn .� „ « nnnnnnnnnnnnnnnnnnnnnnnnn . . nnnnnnnnnnnnnnnnnnnnnnnnn l,�'nnnnnnnnnnnnnnnnnnnnnnnnn �,« nnnnnnnnnnnnnnnnnnnnnnnnn (Print or type) (� Check one: Certificate Installing Company Name v�nFlLt c PJ i�1� 1rn�� �j•tt.AC.� LVS ® Corp. Address LA Partner. t ti'v� mousiness Te ep one g _c� rl UJ Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 121 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 11 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 Massachusetts State -Plumbing Code and h`ipter 142 of the General Laws. BY igna ure Of icense um er Type of Plumbing License Title Cit /Town 1\3S� Y cense lNumDer Master © Journeyman 1-1APPROVED (OFFICE USE ONLY ` M DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR & INDUSTRIES NOTIFICATION OF DELEADING WORK 1 All sections of this form must be completed in order to comply with the notification requirements of M.G.L. C. 111 5197 FILE NUMBER UF at Inspector 0 Date of Inspectionw ` Contractor performing project �� /1� cLicense # Address of Project Building Name (if any) Floor �- Street Address City__ l(/_ Zip Deleading Method: DRY SCRAPING HEAT GUN APSULATTON DEMOLITION (circle all that apply) POWER SANDING CAUSTICSREPLACEMENTS OTHER If "Other" selected, please explain Check one: dwelling is Multi -family single family` Start date--� -- 3 Q --- 9'Date--L- When e Completion Dat - A - ` 2 When will work be done: am '✓ pm weekends? ` Project Supervisor Nam 4 '� License # C.J Property Owner_ 1AAQ k e, r- X"-„ n P , Address_ / Y ''-t /,.) q O City_ _ pro ve State /Y� Zip ( /�/� Telephone S - 3 Y q 7 - In In case of emergency, contact what person: S Phone: Area code required day--'s--a LL? /3 /Z evening ay,, (OVER) 0034B/5 rev 11/16/89 A fn accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws C. 111 5197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method(s) removal or covering of paint, plaster soil or other accessible material containing dangerous levels of lead, is to be provided to the following persons at least five days prior to the beginning of deleading. I. Occupants of the dwelling unit 2. All other occupants of the residential premises, if any 3. Director, Childhood Lead Poisoning Prevention Program Department of Public Health, 30,5 South Street, Jamaica Plain, MA 02130 4. Lead Removal Program, Bureau of Technical Services Department of Labor and Industries, Division of Industrial Safety 100 Cambridge Street, Room 1101, Boston, MA 02202 5. Local Board of Health/Code Enforcement Agency 6. Massachusetts Historical Commission (if premises is listed on the State Register of Historic Places) The undersigned hereby states, under the penalties of perjury, that s/he has reed and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CM 22.00, and Lead Poisoning Prevention and Control Regulations, 105 CMR 460.00, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. Date —S'— 9 Z- '��rz e Signed;I;e '/ /1� W Titles _ a__ r _------r`—"` Office Use Only 0034B/6 rev 11/16/89