HomeMy WebLinkAboutMiscellaneous - 19 ELM STREET 4/30/2018 19 ELM STREET
210/042.0-002s 0000.o `. �,
Insurance Adjustment Service
139 Billerica Rd Unit Al
Chelmsford, MA 01824
Phone: 978-256-3334
Fax: 978-256-3354
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTIO 3B �E:''Ys:T.
Date: Jul 17, 2014 JUL .l 201
TO: Board of Health/Building Inspector TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT l
RE: Insured: Jackyoo Lee
Property Address: 19 Elm St
North Andover, Massachusetts 01845
Date of Loss: Jul 03, 2014
Policy Number: 1056871
Type of Loss: Wind
File or Claim Number: 14089473
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6,to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you for your cooperation.
Very Truly yours,
Tim Martino
Adjuster
978-256-3334 ext 135
Date. , 7 .1.7.....................
` OF r10RT/y,�
3?; aoL TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
• I ',:
SSAC*4u /I
This certifies that ..... .." ......Z..//�.A! �"
a ff ........... ......................................
has permission to perform .....�' ::
.. . .. ..................................
wiringin the buildin of........... ..................................................................................
at ....... .. ......... .....i''...........•;�l'✓I........:Y`.......................PiCiAiL�&SPECTOR
h ndover,May
ss.
Lic.No. .0 '.........1..� .....
.......... ................ ..
/ L ELE
Check# J
Commonwealth of Massachusetts Official Use Only
'1 Permit No. /01 3
a Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00
(PLEASE PRINT IN HK OR TYPE ALL INFORMATION) Date: J --f— zw
City or Town of. NORTH ANDOVER To the Inspector of Wires.-
By
ires:By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) / 4 EL~,
Owner or Tenant :�peK-foy Le-e Telephone No.
Owner's Address 1.
Is this permit in conjunction with a building permit? Yes ❑ No Eg- (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service /Dv Amps /20 / ZyjVolts Overhead[�J, Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity '-� ► a �(,�.�
Location and Nature of Proposed Electrical Work: �
Completion of the following table maybe waived by the Inspector 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 Abovernd. ❑
No.of Receptacle Outlets No.of Oil Burners 1�,� 4 C)No.of Switches No.of Gas Burners
No.of Ranges No.of Air Cond. Tot:Ton
No.of Waste Disposers Heat Pump J.Ng.Ml er I Tons �^
Totals:
No.of Dishwashers Space/Area Heating KW
No.of Dryers Heating Appliances Ii
No.of Water No.of No.of
Heaters I Signs Ballast,
No.Hydromassage Bathtubs No.of Motors Total I,,
OTHER:
Attach additions
Estimated Value of Electrical Work: (When required'.
Work to Start: -'bo-/e-- - 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I"certify,under thepains andpenalties ofperjury,that the information on this application is true and complete.
FIRM NAME: . �Oc C J A.Aj C LIC.NO.:
Licensee: ,l) �'�.. ���u Signature c- = LIC.NO.:
(If applicable,e empl"in the license num er line.) Bus.Tel.No..•
Address: p' 604" ��/I/ , .v��✓�, � O , � Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security ork requires Department of Public Safety"S"License: Lie.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 [PERWTFEE:$
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑
❑Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass n Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 0 Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION: '
Pass M Failed Re-Inspection Required($.) ❑ ,
Inspectors Comments:
Inspectors Signature: Date:
FINAL IN TION:
Pass 0 Failed Re-Inspection Required($.) ❑
Inspectors C ments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
Commonwealth of Massachusetts Official Use Only
A Permit No. hll 3
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] peaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00
(PLEASE PRINT IN NK OR TYPE ALL)NFORMATIOA9 Date:
City or Town of. NORTH ANDOVER To the Inspector of Wires.-
By
ires:By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 1 I CL
Owner or Tenant Qek-tou Lep Telephone No. Ifo 6Zr
Owner's Address 4§• - -----
Is this permit in conjunction with a building permit? Yes ❑ No ®--- (Check Appropriate Box)
Purpose of Building Utility Authorization No.
- Existing Service /oc, Amps 1W jyjVolts Overhead[jq- Undgrd❑ No.of Meters �
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity ��j ( LZ_• p�.t`�-�.
Location and Nature of Proposed Electrical Work: �f�
Completion of thefollowing table may be waived by the Inspector 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- ❑ o.-OTEmergency Lighting
rnd. grnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
...... .. . .......................................................
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:''
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters Signs Ballasts No.of Devices or Equivalent
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: (When required by municipal policy.)
Work to Start: 'b o-/e-- - 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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and Pena,aIties ofpnerjury,that the information on this application is true and complete.
FIRM NAME: . Oc ' Com' Co LIC.NO.:
Licensee: ",�q?k 'W4"u 4 Signature r----- LTC.NO.:
11.1
(If applicable,end empl"in the license num er line.) n ^ Q Bus.Tel.No.•
Address: Lw�t(�c, C�/y .,4-v���c'-. 7'Y ' O j7ci eb Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security Mork 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.- $ 3-5--
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012.
❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑
❑ Permit Extension Act—Permit/Date Closed:
Trench Inspection
Pass M Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments:
Inspectors Signature: Date:
SERVICE INSPECTION:
Pass M Failed 0 Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
PARTIAL ROUGH INSPECTION:
Pass 1E Failed Re-Inspection Required($.)❑
Inspectors Comments:
Inspectors Signature: Date:
ROUGH INSPECTION:
Pass❑? Failed 0 Re-Inspection Required($.) ❑
Inspectors Comments: '
Inspectors Signature: Date:
FINAL INTION:
Pass IN Failed Re-Inspection Required($.) ❑
Inspectors C ments:
Inspectors Signature: Date:
DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
qV 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le0bly
Name(Business/Organization/Individual): 0 e S
Address: 22_�C,&), J�i
City/State/Zip: �ti. ice��Ovt� Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.V34 am a employer with '�> 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have Hired the sub-contractors
2.01 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and'have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. El We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
03.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 1211.Roof repairs
insurance required.]i employees.[No workers' 1311 Other
comp.insurance required.]
*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 ace doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that checkthis 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:. cko_
Policy#or Self:-ins.Lic.#: Expiration Date:
Job Site Address: /7 E Si City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
&C 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 cert under. m pain VA of-T r'ury that the information provided above is true and correct.
Si ature: Date:
-7- 1Li
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#:
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 ofhire,
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 an 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 ofpublic 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 permittlicense 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 (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 burn 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
604 Washington.Street
Boston,MA,02111
Tel.#617-727-4900 ext 406 or 1.-877- T.ASS.A.FE
Revised 5-26-05 Fax,#617-727-7749
www-wass,gov aia
Date.
<",O RT"
01 �� TOWN OF NORTH ANDOVER
. o
8 � s
PERMIT FOR PLUMBING
• i a
°•A�`49
,SSACMUS�
This certifies that . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . . . ,,�. . . .'.. . '. ",. . . . . . . . . . .- '. . . . . .
plumbing in,the buildings . . . . . . . . . . . . . . . . . . . . . . . .
... . . . . . . . . . . . . . . . .. North Andover, Mass.
Fee,'..— ! . .Lic. No.!. . ... . . . . . . . . . . . ./.. . . . . . . . . . .
PLUMBINGI16PECTOR
Check # `3 L
L7t� vJ
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS "6 3"
Date
Building Location C—L S T Owners Name SA(- I-e�'yy Lee—
Permit#
Amount c>a
Type of Occupancy
New Renovation Replacement b Plans Submitted Yes ❑ No
FIXTURES
SLRH C
1S>C)HIODit
ZD IIUQZ
3M
4IH)EIOCR
6MEL"
7MH>I M
8MM DM
(Print or type) ��/ �p Check one: Certificate
Installing Company Name O fie' L...✓I R-Grp. �( C
LJ �
Z� t�6
Address Partner.
ILO t'.I L L-t— rA- t rf:�� Z 11
Business a ep one 7 �6 1-f -S-2—c-( (.- 11 Firm/Co.
t
Name of Licensed Plumber. Lam. V-1 Sit U A
Insurance Coverage: Indicate the ty insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity 0 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
rgna ure Owner ❑ Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachysetts� 'State P um God and Chapter 142 of the General Laws.
BY ign l`--� s
Type of Plumbing License
Title ( 2-q-3 Lo
City/Town License lNumBerMaster Journeyman ❑
APPROVED(OFFICE USE ONLY
Date. .. .r. . �..r.�. .
NORT1y
Of ..ao ,°,'t'O
o? TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
�y
SSACH U5Et
This certifies that . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . . . . . . . `::: . . ... . . . . . . . . .
in the buildings of . . . . . . . �. . . . . . . . . . . . . . . . . . . . . . .
atU . .. . ... . . . . . . . . . . . . ,, North Andover, Mass.
� r
ee:. . : . . . . Lic. No./. . . . . . r.�. . :. :: := . . . . . . . .
J
GAS INSPECT4R
Check# —�
o
MASSACHUSErIS UNIFORM APPLICATON FOR PERNllT TO DO GAS F rnNG
(Type or print) Date �� --c.)
NORTH ANDOVER,MASSACHUSETTS
�
Building Locations ` l , Permit# a99
Amount$
Owner's Name
New❑ Renovation ❑ Replacement Plans Submitted ❑
o �
WW O U 00 H
000
C7 � H O O
U>
H vHi
`
U q �
z z o•
o o W
O p 3 O U oG A a E+ O
SUB •BASEM ENT
BASEMENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . FLOOR
` EA
(Print or type) Certificate Install"ng Company
Name J n�! a _ l Corp. 1
Address
S ❑ Partner.
L'�tom' - C_ y�,76- Z
usmess a ep one7 S7 f 7— / ❑ Firm/Co.
Name of Licensed Plumber
or Gas Fitter _ j—z)x,,�
INSURANCE COVERAGE
Check on
I have a current liability Insurance policy or it's substantial equivalent. Yes No❑
If you have checked Les,please dicate 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:
iSignature 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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massach=aadZhapte 142 of the General Laws.
Signature of Licensed Plumber Or Gas Fitter
By:
Title � Plumber l'Z 013 So
City/TownGas Fitter License Number
R
Master
PROVED(OFFICE USE ONLY) ❑ Journeyman 3
�.-��