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HomeMy WebLinkAboutMiscellaneous - 188 BEAR HILL ROAD 4/30/2018I 0 rn � m o � Or O Pu O D 60 O Date ... 31 b:41.n ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .........N.....�..� D ........................................................ has permission for gas installationeu'4-,......1,-5pz . . ..... inthe buildings of ............ .............. ................. .............................................. at .......... ......� r ... . .... t .. tA� ....... .41..........., North Andover, Mass. Fee -3.11-f.-!: ..... Lic. .......... ..... ................................................ GAS INSPECTOR Check# N �I G - L. 6 "I �- U, . r 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 compliance iAo all Pertinent provision of the Massachusetts State Plumbing CodeandChapter 142 of the General Laws., 2 �C PLUMBER/GASFITTER NAME: air Y-, LICENSE # —SIGN4ATLTR.E COMPANY NAME: M CLC,E ADDRESS: f nrrt + S f CITY: 1-0*2 TEL:$ �3G"Z19 3 CE�,-9 6- MASTER OK JOURNEYMAN ❑ LP INSTALLER 0 STATE, A ZIP: G (_�'i FAx: / S 3 EMAIL: CORI ORATION [,_� # .30)66' PARTNERSHIP E3# LL MASSACHUSETTS UNIFORM A PLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE ORd PRINT CLEARLY CITY: MA. DATE: 7 ' PERMIT # ` I JOBSITE ADDRESS: t ( OWNER'S NAME: (; c ADDRESS: L I TEL: l0 • jqq 0 FAX: �] �I � � ?• OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL RESIDENTIAL NEW:V RENOVATION :.❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO APPLIANCESZ FLOOR- Bsmt 1 1 2 31 1 4 5 6 7 8 1 9 10 11 12 1 13 14. BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE ASt,(-4- I FRYOLATOR FURNACE i GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER RO F TOP UNIT TEST UNIT HEATER UNMENTED ROOM HEATER WATER HEATER I * M - I INSURANCE I have a current liabili insurance policy or its substantial equivalent If you have checked YES, please indicate the type of coverage LIABILITY INSURANCE POLICY Ua OWNER'S INSURANCE WAIVER: I am aware that the licensee Massachusetts General Laws, and that my signature on this pirmit 1 COVERAGE which meets the requirements of MGL. Ch. 142 YES ff"N0 ❑ by checking the appropriate box below. OTHER TYPE INDEMNITY ❑ BOND ❑ does not have the insurance coverage required by Chapter 142 of the . application waives this requirement. , CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 compliance iAo all Pertinent provision of the Massachusetts State Plumbing CodeandChapter 142 of the General Laws., 2 �C PLUMBER/GASFITTER NAME: air Y-, LICENSE # —SIGN4ATLTR.E COMPANY NAME: M CLC,E ADDRESS: f nrrt + S f CITY: 1-0*2 TEL:$ �3G"Z19 3 CE�,-9 6- MASTER OK JOURNEYMAN ❑ LP INSTALLER 0 STATE, A ZIP: G (_�'i FAx: / S 3 EMAIL: CORI ORATION [,_� # .30)66' PARTNERSHIP E3# LL Departments of -industrial Accidents Office, ofInvestigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 wwiv.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): A di % tE i Q /� i Address: 31 -�c��A S 7— City/State/Zip: %yi,, r _J Phone #: �' �7 9–" 9-34-' Z 15 3 Are you an employer? Check the appropriate box: ; 1. E I am a employer with .3 4. ❑ I am'a general contractor and I Type of project (required): 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' comp' insurance' 9. ❑ Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10. Electrical repairs or additions ❑ P 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 13. ' Other 4:7-. i I�� employees. [No workers' comb. insurance reouired.l *Any applicant that checks box #1 mast 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 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. 11-01, �� JJ /` j( Insurance Company Name: 11.01, T fQYc� ' "_ i Policy # or Self -ins. Lic. #: 6 )?/,+V�l 0 � ->6 Expiration Date: Job Site Address: �ZC 0 3QOf �i �` City/State/Zip: oins 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. provided above is true and correct. Phone #: /— % 7e – R3 e�' Z f 5 3 . Official use only. Do not write in this area, to be City or Town: by city or town official Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CiOy Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other i Contact Person: Phone #: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY1 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(les) 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 CONTACT Bernadette M. Davis, CPCU EA Stevens Company, Inc. � PHONE (781)322-2324 389 Main St.FAX A/C No: (781)397-7672 E-MAIL ADDRESs,bernadetted@eastevensins.com P. O. BOX 188 MaldenMA 02148 INSURERS AFFORDING COVERAGE NAIC # INSURERA-Martford Fire Insurance Com an 19682 INSURED MAGNIFICO BROTHERS PLUMBING INSURER a.Safety Ins 9454 HEATING & GAS FITTING LLC i INSURERC.Twin City Fire 29459 31 FOREST STREET INSURER D: MIDDLETON INSURER E MA 01949 - �.trt I tru:w I E NUMBER3�aster 2014-15 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 j AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP GENERAL LIABILITY M1DD LIMITS EACH OCCURRENCE $ 1,000,00 S COMMERCIAL GENERAL LIABILITY - DAIM-GE TO RENTED A CLAIMS-MADEPREMISES Ea occurrence $ 300, 00' $ OCCUR SSBAUQ5370 /24/2014 /24/2015 MED EXP (Any one person) S 10 OOt � r PERSOIAL &ADV INJURY $ 1,000,00( GEN'L AGGREGATE LIMIT APPLIES PER: PRO B 1 POLICY r7 LOC GENERAL AGGREGATE $ 2,000,00( PRODUCTS -COMP/OP AGO S 2, 000, OOC $ B AUTOMOBILE % LIABILITY ANY AUTO ALL OWNED x SCHEDULED AUTOS AUTOS HIRED AUTOS B AUTOS ED AUTOS � 053635 I , /24/2014 /24/2015 COMBINED SINGLE LIMIT Ea accident)$ _ 1100010010 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ P OPERTY DAMAGE Per accident $ ::::]- $ A X UMBRELLA LIARL EXCESS LIAB I OCCUR CLAIMS -MADE OBSEAUQ5370 /24/2014 /24/2015 EACH OCCURRENCE $ 1,000,000 DED I $ I RETENTION$ 10, 0OC AGGREGATE $ 1,000,000 C WORKERS COMPENSATION AND EMPLOYERS' LIABILITYWC ANY PROPRIETOR(PARTNER/EXECUTIVE Y/N OFFICER/MEMBER EXCLUDED? (Mand If yes, describe under DESCRIPTION OF OPERATIONS below N/A 8MCRT9050 /24/2014 /24/2015 $ STATU OTH- E.L EACH ACCIDENT $ SOO 0OO E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 i DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hartford Fire Insurance Company ACCORDANCE WITH THE POLICY PROVISIONS. One Hartford Plaza Hartford, CT 06155 AUTHORIZED REPRESENTATIVE It 4 Thomas Cares, Jr/ML d� ACORD 25 (2010!05) ©1988-2010 ACORD CORPORATION. All rights reserved. (NSn95 r.,n,nnsi m T1t0 A/InQI1 nantn onrl Innn nrn ronictororl r+.�r4c of A(_ARrI I tsUARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP u MARK MAGNIFICO t. ,\•� MAGNIFICO BROS PLB&HGT,GAS FITTI w 31 FOREST ST MlDDLETON I MA 01949-2015 \NN — 326.6 05/01/16 204666 L _ COMMONWEALTH OF MASSACHUSETTS BOARD OF - PLUMBERS AND GASFITTERSS ISSUES THE FOLLOWING LICENSE LICENSEDIAS A MASTER PLUMBER MARK B MAGNIFICO >> Z ,0 55 31 FOREST STREET`' 141DOLETON IMA 01949-2015 13559 05/01/16 204667 C0! 'MOON E H `� *MASSACHUSETTS r. _ 4 .-.2 BOARD OF ' PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBER r MARK B MAGNIFICO r z 31 FOREST ST 2 M I D€ LETON MA o t 949-2015 25002 05/01/16 204668 Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ .. .... .................... ...... A ..... C ..................... ii" ............ ........... has permission to perform ....... ...... . ..... ......... wiringin the building of ....... I ............... ...... N ................................................................ at ..... x'1..1... ...,�f .... ....... C) ............. .... ... .North Andover, Mass. . Fee. "t7- . ............ Lic. No. VLIZI..74 ............. ECT AL INSPEGTO'R Check # ?—n 3 Commonwea& o f Mamacht ffj aL. partmertt W Jim Seruice.4 BOARD OF FIRE PREVENTION REGULATIONS Pel Form Official Use Only Permit No. 131 � Occupancy and Fee Checked [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 IN INK OR TYPE ALL INFORMATION) Date: 3/5/15 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)188 bear hill road Owner or Tenant Priscilla fox Telephone No. 978-685-1440 Owner's Address same Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building dwelling Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: one afci receptacle outlet for fireplace gas insert Completion of the followine table may be waived by the Imnector of Wires_ No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- El. o Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets 1 No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number I Tons I KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances Kms, Security Systems:* No. of Devices or Equivalent No. of Water Kms, No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring No. of Devices or Equivalent OTHER: 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: 3/5/15 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: lance macinnis electric f _ LIC. NO.: 21217a Licensee: lance macinnis Signature (If applicable, enter "exempt" in the license number line) Address: 12 locust street middleton ma 01949 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Pu lic OWNER'S INSURANCE WAIVER: I am aware that the Licensee does required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature Telephone No. LIC. NO.: Bus. Tel. No.; Alt. Tel. No.: 5087260802 afety "S" License: Lic. No. not have the liability insurance coverage normally I am the (check one) ❑ owner ❑ owner's a ent. PERMIT FEE. S 3/s��sp� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): lance macinnis electric Address: 112 locust street City/State/Zip: middleton ma 01949 1Phone #: 508-726-0802 Are you an employer? Check the appropriate box: 1. IM I am a employer with 1 4. [0 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. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [3We are a corporation and its required.] ®1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ® New construction 7. 13 Remodeling 8. ® Demolition 9. ® Building addition 10. M3 Electrical repairs or additions 11. [3 Plumbing repairs or additions 12.[0 Roof repairs 1313 Other *Atny 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. $Contractors 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: the hartford Policy # or Self -ins. Lic. #: 21.217a Expiration Date: 11/1/16 188 bear hill north Job Site Address: road City/State/Zip: andover ma Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiopqunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a file up to $1,500.00 and/or one- y ar mprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day agains e v olator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fp s ance coverage verification. I do hereby certify id Vains and penalties ofperjury that the information provided above is true and correct. Signature: Phone #: `� -` """��` -- - Official 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 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: a I r COR�iMOi1lV!.`gL7N 41` M,4 --"_ smis BOARD O� ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS q REGISTERED MASTER ELECT f LANCE D MACINNIS /. 12 LOCUST ST 1 U MIDDLETON MA 01949-1206 2121 �" A 0&/, 96024 LL . r,. . Date. .. l ... . Of .NOQTN TOWN OF NORTH ANDOVER A PERMIT FOR GAS INSTALLATION This certifies that ..... N. (� ��. 5-C2 ......................... has permission for gas installation ..r-`//?�#14— C. r......... . in the buildings of ....F.o.,?............................... at .. I.Y - 3 .k. ��eXt .Z/ ........... North Andover, Mass. Q Fee.,, -7 J-- ..... Lic. No..Y�`.'.... GRAS INSPECTOR_ Check # 343 b3�9 C!' M.pz MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Prim or Type) N' oU1:—a`y� -,Mass. Date 0. l��'6'p'. Permit # 3 3i Building Location % O E &P` 4d 16D Owner's Name &l S GC / //+ iC Owner Ter( l 7 16 d S 9 U Type of 0=1pa Re S'DL- Wr/ 1r L New 0 Renovation 0--'Rep11ceme W O Plan Submitted: Yes O No 0,,-- FIXTURES ,/FIXTURES Installing Corn pany^Name CO Check one: Certificate Address t q Q ,SO u7 -N A91'N ST 0 Corporation Q p, / D D LETo-N rl o 1 7 / O Partnership Business Telephone 9 % �(Firm/Co. Name of Licensed Plumber or Gas Fitter l� % C N 1r Q R y S 0 r') INSURANCE COVERAGE: have a ctxrent meets th bb@ty Insurance policy or its substantial equivalent which e raqutrements of MGL Ch. 142. Yes No O if you have ed n}, please Indicate the type coverage by chedrkp the appropriate box. A Itabifmty Wi=ns poticy * Other type of Udemnity a Bond O OWNER'S INSURANCE WAIVER: I am aware that ten f1cm gM not hm the kmatxancs coverage required by Chapter 142 of the Mass. General Lom and that my signature on this permit appkR-m walwa this requirement Cued one: Owner a Agent o Signature of Owner or Owner's Agent I heraby certify that aft of the details and Information I have submitted (or en knowledge and that an plumbing work and Installations performed under the >ertinerm provisions of the Massachusetts State Goa Coda and Chapter 142 By Type of Ucens6: -Plumber rrtle -0as fitter Master Cityfrown • Journeyman APPROVED (OFFICE USE ONLY) am"and *Danita to the test or my Issued for Umb spOlcoW wM bo Ip-m—nptianoa with all Ucense Number q 0 0 1 A i a s a S .� •Itl ■■■■■■■■■■■■■■■■■■■■■■■■■■ Installing Corn pany^Name CO Check one: Certificate Address t q Q ,SO u7 -N A91'N ST 0 Corporation Q p, / D D LETo-N rl o 1 7 / O Partnership Business Telephone 9 % �(Firm/Co. Name of Licensed Plumber or Gas Fitter l� % C N 1r Q R y S 0 r') INSURANCE COVERAGE: have a ctxrent meets th bb@ty Insurance policy or its substantial equivalent which e raqutrements of MGL Ch. 142. Yes No O if you have ed n}, please Indicate the type coverage by chedrkp the appropriate box. A Itabifmty Wi=ns poticy * Other type of Udemnity a Bond O OWNER'S INSURANCE WAIVER: I am aware that ten f1cm gM not hm the kmatxancs coverage required by Chapter 142 of the Mass. General Lom and that my signature on this permit appkR-m walwa this requirement Cued one: Owner a Agent o Signature of Owner or Owner's Agent I heraby certify that aft of the details and Information I have submitted (or en knowledge and that an plumbing work and Installations performed under the >ertinerm provisions of the Massachusetts State Goa Coda and Chapter 142 By Type of Ucens6: -Plumber rrtle -0as fitter Master Cityfrown • Journeyman APPROVED (OFFICE USE ONLY) am"and *Danita to the test or my Issued for Umb spOlcoW wM bo Ip-m—nptianoa with all Ucense Number q 0 0 1 MASS'ACHUSET rs IN PL41 iS -" Wb I'XA§ ITTERS;i L' ICE.NSED'J:OU NE'. ETO GASFITTE ISS y��\'17jJ�. MICHAEL & N,. - 16 NICHOL �' Vgry LYNN V,°. 0^02-371a �,A/UfQ3t�1`�b` i 40.0; h0�5%^}�..'., I X25.9163 ' ... COMMONW `LT OF.•MA$SACHUSETTS DIVISION OF PROFESSIONAL LICE NSURE IN PLUMBERS AND.GASFITTERS LICENSED AS 'AN;,L-P••-GAS INSTALL Is3yE TNIs'.i�CEr�sE TO 14ICHAEL A l6 NICHOLS AV8ffVE':. LYNN "� •01iri02-3718 • ule�t; � 93333.�� 0�/.g liol 259162 0 13 ACS=. CERTIFICATE OF LIABILITY INSURANCE 11/25/2007' vaooum (978)922-2288 FAX (978)922-2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Appleby i Wyman Insurance Agency Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 152 Conant St. ALTER THE COVERAGE AFFORDW.BY THE POLICIES BELOW. Beverly, MA 01915 Susan Rubin INSURERS AFFORDING COVERAGE NAS INSURED Michael A. Bryson INSURERA: National Orange insurance Co. 14788 DBA: c/o TYS, Inc. INSURER B: 140 S. Main St. INSURER C: Midditon, MA 01949. INSURER D: INSURER E: kddXREWMASM THE POUCIES 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 CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. to TYPE OF INSURANCE POLICY NUMUR Zramm. P 1 LIMITS GENERALUABS.ITY MP092$21 11/01/2007. 11/01/2008 EACH OCCURRENCE s lfowlwol DAMAGE TO RENTED = SO X COMMERCIAL GENERAL LIABILITY MED EXP (Any one person) S 5,00 CLAIMS MADE a OCCUR - PERSONAL d ADV INJURY f 1 f 000, A GENERAL AGGREGATE $ 2,000, GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG f j r 000 POLICY JPE4 LOC - AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT f (Ea S=Werlt) BODILY INJURY f (Per person) —_ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY – f (Per acoioent) HIREDAUTOS NON-OWNEDAUTOS PROPERTY DAMAGE f (Per accident) GARAGE LIABILITY AUTO ONLY. EA ACCIDENT f OTHER THAN EA ACC f ANY AUTO AUTO ONLY: AGG f EXCESSIUMBRELLALIABILny EACH OCCURRENCE $ AGGREGATE f OCCUR F] CLAIMS MADE s $- DEDUCTIBLE s --RETENTION S W TATO TK - I ER WORKERS COMPENSATION AND E.L. EACH ACCIDENT f EMPLAYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE f E.L. DISEASE •POLICY LIMIT f M yes dcribe under SPECesIAL PROVISIONS belga OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS TOWN OF NORTH ANDOVER ATTN: GAS INSPECTOR 146 MAIN ST NORTH ANDOVER, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLK=f BE CMGZLLED SUO ME THC EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL I Q_ D03 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALL BMPOSE NO OBLIGATION OR LLAT LITY OF ANY IOND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 11 A. Carmen Marc i ano/CRESCI I a�'r" `-' �•''� ', ACORD 25 (2001108) FAX: (978)774-3344 PDF created with pdfFactory Pro trial version www.pdffactory.com CACORD CORPORATION 1988 0 I The Commonwealth of Massachusetts Department of Indusrial Accidents IFUOffice of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): A/�—_,f / Address: /`f O So u T� Ag4i s T' Ci A14 Phone #: Are you an employer? Check the appropriate box: 1. 21 am a employer with S 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. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance? 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. O'RRemodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I L ❑ 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. 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: �/�/OL �y 9l Y�gA) S S(J2/GAJ� /�c�G y --L rJ, C - Policy # or Self -ins. Lic. #: , 6,0 C Q Y 6 9 3 Expiration Date: 0/ Ad SJ „/0 lnh Qita ArlrirPec• /(�J /J, L L9h City/State/Zin: 2 AA ,ol7y5� 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the Dl&for insurance coverage verification. I do hereby cert6 yitdef the painAand penaltie, f of perjury that the information provided above Is true and correct Phone #: ` % e /3 Q Official use only. Do not write in this area, to be completed by city or town gfjFiciaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Date .......... /-,o -7 ............. F ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......... C ........ .. .............. has permission to perform ...... �e�f ... ?-.f ...... wiring in the building of F .......................F5 ....................................... at ........ Iff-f-I F--!9 ........... North Andover, Mass. ... ........ Fee .���- Lic. No. .C?494�!��7 ........... .— I.i ... 4�� cle 3 ELECTRICAL NSPE. R V Check # 7426 S -IN Commonwealth of Massachusetts Official Use Only Permit No. % Ll 2-,4 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 6 —1 — 0 -?- City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of hi or her intent. to perform the electrical work described below. Location (Street & Number) /$ � ��eG � c �� P: Owner or Tenant -Po S C L i I,� p K Telephone No. 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 New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity �- Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Insvector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. oTotal Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ o. of Emergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. oT Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump I Number I Tons KW No. of elf -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances Kms, Security Systems: No. of Devices or Equivalent No. of Water Kms, o. o No. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (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 ' urance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under th us anq penalties of perjury, that the information OJ# till's applicat' n is true and complete. FIRM NAME: / �I _ %tr telt n/ LIC. NO.:Z�7-47`�-i Licensee: "I ' Fu til Signat re � LIC. NO.: (Ifapplicable, enter "exenlp " in the license numb(r line.) Bus. Tel. No.-9.4-44�-V- e � Address: NO.oto/ dl Alt. Tel. No.: *Per M.G.L c. 147, s.% 7-61, security work requires Department of Public Safety "S" License: Lic. No. 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. Owner/Agent PERMIT FEE: $ Signature Telephone No. Em r64,t w.J &A� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individ Aj Address: I KA+mo City/State/Zip: P Q�, Auxyiu ✓UPhone #: `� 1 F — 4- -, ,3 Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I ployees (full and/or part-time).* have hired the sub -contractors. 2.0 I am a sole proprietor or partner- listed on the attached sheet. $ ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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 I l.❑ 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. $Contractors 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: /Re gec r City/State/Zip: Pd- A,04;1Lr& "U__ 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 wider th r quad penal s of perjury that the information provided above is true and correct. Date: Phone #: '17 S-- ( 9-9 — 9 -33 Official 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 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: N2 2668 Date.... A / (-) TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... �............ ... ........................................... ... ... ... has permission to perform ............ .................................... wiring in the building of ..... r7. .... fgZ?k ............................... at . ....... ­,North Andover. Mas, e5 Fee ... 15.".: ....... ..... .E.C..TOR ..iLEcrRiCAL INSP Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 7HE0UMM0NWF.4LTH0F1 J4WC71USE77S OfficeUseon l y DEPART1tfNTOFPUBLICS4MY Permit No. BOARD OFMEPREVEM70NRECULA7I0AS527CMR 12-00 V Occupancy &Fees Checked A PPLICATIONFORR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat 1 2 Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 1 0 oaf fig i I \ �o�—c� wx C, , A X cQ Ca L P.rt t A44- I-, I J'Y S Owner or Tenant O-C>le /4 Owner's Address ISJ `11--< Pow , Is this permit in conjunction with a building permit: Yes a NoED' (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps` / Volts Overhead Underground No. of Meters New Service Amps / Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work pe. a v �c32o � y�Oco No. of Lighting Outlets No. of Hot Tubs/ No. of Transformers Total KVA No$ of Lighting Fixtures Swimming Pool Above Below Generators KVA ground 1:1ound No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipala Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis 1 Q. Hydro Massage Tubs No. of Motors Total HP O- HER hsttarneCotaage Rnsuart1Dthetatl cmertsdMass�GalaalLaws ItmeaanatLiabkyhNr&roePdyffrkdngCanptete Baa' crAsskswUeWivA>< YES E3 NO Iha\estftn&dvandptooffofswriDtheOffioe YES o r7 If}uutmedw3cedYES,pieasemc}c*thei�WcfomWbydcdmgthe WpopriMebcDc INBOND r7 OTHER F7 ftmspe* 2— ii A&A �' Eshm&dvaluedE chmlwadc $ WakioSlatt J0124/60 lnspec6mD*RalZW Rough Fatal signed unciaTie %wiesofp�ygy FIRM NAME %� > 6 �-� P A4a" L ► _ LiWWNa Si". Limmilb "'p+( T—Busim Tel. Na Esq Qe.-.CG t -,-K ccc--4 1 AIL TeL Na OWNER'SINSURANCEWANER;Iama%NwedAthelxensedoes�x el the itnlrano wvtrgea-ilssbstifiilWWatast gmWbyMas d setGataWLaws andditmysigtr mcnthepamitappticadmwaivesflusWit. (Please check one) Owner o Agent ED/ ,1 l Telephone No. PERMIT FEE $ �� V v N2 3 14 3 Date.. ...............u/ TOWN OF NORTH ANDOVER 0 0-p PERMIT FOR WIRING 4L This certifies that ..... 1kf q 0 7 (' ................................................................ 5-e-, I -e . .... &: ........................................ has permission to perform ............ Afy'!� ...... wiring in the building of ..........1......%.11....................................................... at .............. ......... North.,'"dover, Mass. Fee.:/,I�.Ia�.... Lic. No,.. .... .................. ELECTRICAL PER Check # 169,1 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer �-\ THECIRWO VWGf UH0FAMNS4CH(I.SL I S Uttice Use only DEPAR73ffi 0FPUBLICSAFM Permit No. � BOARD 0FFIREPREVEM70NRWUL4T10NSS27CMR 12.-00 Occupancy & Fees Checked APPUCATTONFOR PERAff TO PERFO.RMELECIRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR.TYPE ALL INFORMATION) Dat ;/ / G Town of North Andover To the I spector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street d Owner or Tenant Owner's Address / j c- /&Q Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building S /-t �Ge� �C.�-cam x n. Utility Authorization No. Existing Service Amps / olts Overhead a Underground No. of Meters New Service Amps Volts Overhead r-1 Underground r --J No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs No. of Transfonners Total KVA No. of Lighting Fixtures •ground Swimming Pool Above ci Below m Generators KVA ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. taf Switch Outlets No. of Gas Bumers FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydra Massage Tubs No. of Motors Total HP OTHER- _s 4c e_D AL 0, 1- InstranoeCO RM3ntbthetegtt6a Laws Iha%ea=utLi bdtylrw==PcbcyerhtdmgCar>plete CovaWeritsmbstatMo*iva1at YES NO Iha%e%lbmi&dvandptodofsi¢netutheOffm YES MNO n Ifjcuha%edvd dYES,pimeadic*ihe WofmaWbydakirgthe `� fir' ! ��.:•1.1 / :�._ • :.• :F:. FIRMNAME ftffle) FwdValueec(Ekctlical Wak $ C,A2i Final LiarseNa /�� -f J� Lica ��tit I-V G(/� ��� Signattne Lia�seNo BtzattessTCL Na OWNER'S PgRAZANCEWANFR;Iamawac dAlheLiw=dm not anddmtmysigt mcnfltispem-d pplckmv4aimsthisrmp'ff Tint. (Please check one) Owner M Agent ok^ 6-<X AI[TeLNa h dbyMassadxsws Cataal Laws Telephone No. PERMIT FEE Date.. C'. a ..�.Q.C( ... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION _700 - This certifies that .. 1</).,Pw, r u has permission for gas installation ..... p ..�A.. .� ...... in the buildings of . c9r.................................. at .. S B �a.r . «... ''o......... , North Andover, Mass. -* Fee.30 `�� Lic. No.l.r.?9l..... Xt .t? 1PXit GAS INSPECTO� Check # f a.-) o' . MASSACHUSETTIS UNIFORM (Type or print) NORTH ANDOVER, Building Locations Owner's Name New 21� Renovation ❑ Replacement ❑ FOR PERMIT TO DO GAS FITrl' NG Date Plans Submitted ❑ Permit # 6P Amount $ (Print or type) Name Address Name of Licensed Plumber or Gas Fitter NN n Check o Certificate Installing Company r` �C Corp. J ❑ Partner. �ji� ❑ Firm/Co. 'VII GVM n P.M INSURANCE COVERAGE k-11CUx u„c. I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked }_es, please and to 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 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 performe under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac> istts,St is C4 and �;hapter 142 of the General Laws. py: Title City/Town APPROVED (OFFICE USE ONLY) 'gnature of Licensed Plumber F' Plumber ❑Fitter (cense um er Master r-1 Journeyman � a U a x � w c7 W p UO co N x Cn O a� � F W O G •-� O z W, H W � x w W F p. O a FM � GC7 a W a z � W d a �, C �¢ 0 O O W C U C4 A a F O SUB-BASEM ENT BASEMENT WTI 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . F L O O R 5TH. FLOOR 6TH. FLOOR - 7TH. FLOOR I I T STH. FLOOR (Print or type) Name Address Name of Licensed Plumber or Gas Fitter NN n Check o Certificate Installing Company r` �C Corp. J ❑ Partner. �ji� ❑ Firm/Co. 'VII GVM n P.M INSURANCE COVERAGE k-11CUx u„c. I have a current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked }_es, please and to 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 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 performe under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac> istts,St is C4 and �;hapter 142 of the General Laws. py: Title City/Town APPROVED (OFFICE USE ONLY) 'gnature of Licensed Plumber F' Plumber ❑Fitter (cense um er Master r-1 Journeyman