The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 21 LINDEN AVENUE 4/30/2018r N2 9636 Date ..o ��. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform ..... ....... ............ t�.� plumbing in the buildings of ...................... at .... ...1...... , ort And ver, Mass. Fee .E.6 .... Lic. No?�-M.�5 .. r� ... . PLUMBING INSPECTOR Check #4';-4r12 . WHITE: Applicant CANARY: Building Dept. PINK: Treasurer FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING : �y CitytTowjjn: / _, MA. Date: JF / j / Building Location- / 6 Owners Name: Permit# AZA/)-. 6V11r, Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residen New: ❑ Alteration: ❑ Renovation: ❑ Replacement• Plans Submitted: Yes ❑ No ❑ FIXTURES INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesj�rNo ❑ If you have checked Yes, please Indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond F1 OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Aaent Owner ❑ Agent ❑ I 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Title City/Town Type of License: 4 � J Ek�iumber Signature of Lice ed lumber ❑ Master [2dourneyman License Number: ) S` z a. � � z Y Q U v t! t7 wR' U) �r Lu Z 9 rn N Q W Z_ � X a rr� x O m XW Q a a. W A 1- Q N~ w O 4 o N R z in to z °- a n. u, o LL �` ~ O 0 H I Z¢ u. CL Y Q= W to LU LU a a w° a o z° a a� °O a R a d a I-- 0 SUB BSMT. BASEMENT 1 FLOOR 2 WFLOOR 3 K u FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR -Y 'FLOOR t /�T" n� " Check One Only Certificate # Installing Company Name: .� � ` �l Address: l�,42LAAC' ityrrown: %%r°774Gse-s-- State: ❑Corporation Zip Code: c)lk,-Irl ❑ Partnership Business Tel: Fax:f 9-7 d�U� rmlCompany Name of Licensed Plumber: INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesj�rNo ❑ If you have checked Yes, please Indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond F1 OWNER'S INSURANCE WAIVER: i am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Aaent Owner ❑ Agent ❑ I 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Title City/Town Type of License: 4 � J Ek�iumber Signature of Lice ed lumber ❑ Master [2dourneyman License Number: ) S` Date. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ................ has permission for gas installation. in the buildings of . . . CA ............................. at ..... �-7 ......... orth An er, ass. Fee. 2-0.... Lic.No. M)K.. rI.P ... GASINSPECTOR Check #2 8399 Eli MASSACHUSETTS UNIFORM APPLICATION MA. Owners Name: TO DO GAS FITTING Permitn Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [' New: ❑ Alteration: ❑ Renovation: ❑ Replacement: [J"' Plans Submitted: Yes ❑ No ❑ FIXTURES x ui f -a Z H fe p =wtu in to w z s = g ro a0 o t- �'�;g Vl W W �' aa0 a LLI 0> M Q to w O = W CL Q iii! 1- W= n x u_ W a ? U W Z t? .! F != O Z J 0 u. W tom. W W t Z W �- W -3 4 4 a0 ui O az tt7C O � O O > > Z > z �a O t0! D tis Ua' t 9 X i3" iw- SUB BSMT. BASEMENT 9 FLOOR 2 No FLOOR 3 FLOOR A FLOOR S FLOOR 6 FLOOR 7 FLOOR 8 FLOOR n /�� / ` `� Check One Only Certificate # Installing Company Name: O✓ 7L- ❑Corporation r` y� Address:rL C'rtyFrown: 1''t �► F1t,1 �0i- State: &.A_ L] Partnership Business Tel: 4g a q?a° Fax: 4� B-Fliffirn/Company lk AV4 k — Name of Licensed Plumber/Gas Fitter: 1. INZUKAPtt.0 t,vvcrwur- i have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes Q o ❑ If you have checked Yew please indicate the type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement Check One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's Anent By checking this box ;1 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 942 of the General Laws. By Title Cityr town — APPROVED USE ONL RPW License: , Plumber Gas Flitter Signature of L nse Plumber/Gas Fitter Master foumeyman License Number: LP Installer t Date .Y....`' ... �� .... . a° ,"`° ;• "� TOWN OF NORTH ANDOVER _ p PERMIT FOR WIRING •"a This certifies that ..... �. �. �� _.::r-. c— .................................... has permission to perform .. :4::. rrr :fes.......... wrong in the building of .......:.............................................. at.. l.--. t- :�::-�- ....................... North Andover, Mass. Feed ... �`........ Lic. No./ -)&,v 4 .................. �.: ELECTRICAL INSPECTOR Check # eL 9361 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.� w Occupancy and Fee Checked --0 [Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code ( EC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: W710 j a City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned Ojves notic s of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant ci 6.t jd Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building _�ReSJP (4 Ct- Putility Authorization No. Existing Service Amps / &1 / 2_40 Volts Overhead rd g Und ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:sC� ZeKava-�,-;ZwJ 4 Cmmnlotinn nfMo fn n.,itin f. Alm .M ,, A„ --;--4 A.. .L No. of Recessed Luminaires - - - No. of Ceil: Susp. (Paddle) Fans ...c "'aGCiOr 01 ry treJ. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ o. o 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. of Detection and " Initiating Devices No. of Ranges No. of Air Cond.� ons No. of Alerting Devices No. of Waste Disposers / Heat Pum Number. T KW .................. No. of Self -Contained / - Totals Detection/AlertingDevices No. of Dishwashers Space/Area Heating Local ❑ Municipal El Other Connection No. of Dryers i� Heating Appliances,, --'KW Security Systems: No. No. of Water ��, Heaters "`� Noof . No. of of Devices or E uivalent Data Wiring: / Si ns Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: If Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of ctric Work: (When required by municipal policy.) Work to Start: / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE E GE: 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 enalties ofperjury, that the information on this application is true and complete/. FIRM NAME:DJ Ul eAyKdvv S LIC. NO.: / Licensee: i Signature LIC. NO.: 21.0 r / (If applicable, enter "exempt" in the license nu�ber line.) Bus. Tel. No. �7 6 ^2�/ 2,6 Address: 1 S� Ca�� ./Jc,� Ajif" G✓��x/r.� f/t% % - Alt f_ S *Per M.G.L c. 147, s. 57-61, se rity work requires Department of Public Safety "S" License: Lic. No� Z� '�� 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 Signature Telephone No. PERMIT FEE: $'a= The Commonwealth of Massachusetts tDepartment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t' 1- www.naass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip: Qr.J _M A-- Phone #:__6 1'7- 6 2.() -Z q Z�(o rlr `ZF J_Z_ j Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ❑ 1 am a general contractor and i mployees (full and/or part-time).* have hired the sub -contractors 2. 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. 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.,525Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other -1Y appuutrr mar cnecKs Dox n i must also tut 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 Names -1 /llW4 W r, � Policy 9 or Self -ins. Lic. #: RO G 6—y? Z — Expiration Date: 11 Job Site Address: City/State/Zip:tlGtdtl�,/ ytPt¢ 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 WOK 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 DCA for insurance coverage verification. I do hereby cert" der ti and penalties of perjury that the information provided a,4ole is true and correct. Sianature� . �2 L--- Date• Phone €: �e 17— Fi 2 C _ Z L" -G 'S - f- _7S_-1.- 1— 0(;9-<P Official use only. Do not write in this area, to be completed by city or town rrfficial. 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 #: Proposal X C _ Invoice GENERAL BUILDING AND CO �'ING 93 Burroughs Road, North Reading, MA 01864 978-551-8020 Sub o: Elaine Gillick Phone: 978-686-6060 Date: 02-23-2010 A ress: 21 Linden Ave Project: Bathroom Renovation Location: First Floor North Andover, MA 01845 We hereby mit specifications and estimates for: -Demo an ei ings, walls, trim, fixtures and flooring, including arch at shower. -Frame new soffit ceiling over tub, new opening for medicine chest in wall and replace I damaged floor joist. -Install new V plywood subfloor over existing floor boards. -Install all plumbing for new toilet, pedestal sink and cast iron tub. -Install all wiring and switches for new GFCI outlet, vanity light and ceiling fan/light. -New fan to be properly vented to outside through exterior wall. -Install hardi backer board in shower area and blue board with plaster though out bath. -Install all tile, selected'by owner, for tub area walls and bath floor. Tub tile to wrap window. -Install wainscoting, selected by owner, either tile or wood, on bath walls. -Install all trim at baseboard and door. -Install all bathroom accessories (towel bars, t.p. holder, shower rod, medicine chest, robe hook). -All debris from demolition: and construction to be removed and properly disposed of, off site. Exclusions: Building permit fees, painting, existing door and window, cost of all fixtures, tile, grout and accessories, and anything not mentioned above. We Propose hereby to furnish materials and labor — complete in accordance with the above do' specifications, for the sum of: , t p4q 2.01& 4 r74y2D' Fourteen Thousand Eight,�Iundred Fifty and 00/1.00 ( $149850.00 ) Payment Terms: 50% down, 35% after all walls up and 15% upon completion. All work to be done in a workmanlike manner according to standard practices. Any alteration or deviation from the above specifications involving extra costs will become an extra charge over and above the estimate. All agreements are contingent upon strikes, accidents or delays �yyond ourfontrol. Owner to carry all necessary insurances. Authorized Signature: Note: This proposal may be withdra7 i by us if not accepted within Z % days. Acceptance of Proposal -- The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined. 2�l 0 r Date of Acceptance: Signature: .a ,40R'r �'14, 0 `• o 504,: Date ...... c'. : /G TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING J$ACNUSE' This certifies that -...... r.`'` ....................... has permission to perform ... .:........... . plumbing in the7buildings of ..................................... at,. / . -- — .............. North Andover, Mass. Fee !�..... Lic. No . G %/L--.. ,% .�,c[,/............. . PLUMBING INSPECTOR Check # —�l/ 8577 110 MASSACHUSETTS UNIFORM "PLICATION FOR PERMIT TO DO PLUMBING (Type or Print) NORTH ANDOVER, MASSACHUSETTS Building Location Owner r New ❑ Renovation Z]' L, , . Replacement Ti yV" TU -1M0 Date Permit #1 Amount Plans Submitted Yes , r No (Print or type) Installing Company Name I Address 69I S4 T Check one: Certificate n Corp. Partner. S—Firm/Co. Name of Licensed Plumber: L i(4 (; f Insurance Covera¢e: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy (-' Other type of indemnity ('i Bond Insurance Waiver: L the undersigned, hSVe been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 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 �Zp lamb' Code and Cha �,.. ��, pier 142 of the General Laws. Byrgnarure or License4allumber— Title Type of Plumbing License City/Town 71,; 2- rcense umoer APPROVED (omcE usE ONLY _Master11 Journeyman 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 Name (Business/Organization/Individual): Address: /; I'cl A� _.._..� City/State/Zip: v l/ l C� �tPhone #: 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 �. 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.] 3. ❑ I am a homeowner doing all work officers have exercised their 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. ❑ Plumbing repairs or additions 12.7 Roof repairs 13. ❑ Other uuL we secrion neon, s na -ng i.: eZr wCi�wV �J�:LYwSats�n policy :..x�o:mY.non. t $omeo""e 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. Lie. #: Expiration Date: Job Site Address: City/State/Zip: `t 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 ofMGL 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 under theins andpenalties of perjury that the information provided above is true an correct Si ature: Date.: LQ Phone #: �� 7 y � E only. Do not write in this area, to be completed by city or town official n: Permit/License # hority (circle one): Health 2. Building Department 3. City/Town, Clerk 4. Electrical Inspector 5. Plumbing Inspector son; Phone #: k, 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 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 co=npliance 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 certificates) 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 rzturned to the city or town that the applica`ion for the pen, mit or license is being requeSted, nest the Departmnent 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 (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 Investibations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 vvww.mass..gov/dia . .....'41- �'S— ......e......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........... has permission for gas instal, ation ............ in the buildings) of ........................ at � / ................. North Andover, Mass. .......... tte .......... Lic. No. Ir, ............. , GASJNSE PCTOR Check # 5321 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFiTTING (Print or Type) 4-1 tVQQ6 61L , Mass. Date 11 las- Permit # Building Location 1 L 1 LLDL LJ A 11E Owner's Name C i' A / iJ -d—ab C/<-,- MOP -T/4 AN D U 1l61L Nil Type of Occupancy_ New ❑ Renovation ❑ Replacement P , Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET RC1 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 9 71B-68,7-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy K . 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 ❑ hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the permit Iss f rpthis application ware true all d a n��mpl ante with ate to the best ll Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene TVDe of License: Title Plumber Signature of cense Plumber or Gas Gasfitter Cit�r/Town Master License Number _3%4'S nrYVED (OFFICE U _ O Journeyman • • • • • MONOSSON 0 MEN wool .. ■!!!!!!M!!!M!!OEM 0 NONE � • • • ■O!!!!!!!OM!!!!!�!!�/!!�!■ rail "M .. ■/!!!!!!�!!!!!!ONE //!■ Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET RC1 Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone 9 71B-68,7-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability Insurance policy K . 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 ❑ hereby certify that all of the details and information I have submitted (or entered) in abo knowledge and that all plumbing work and installations performed under the permit Iss f rpthis application ware true all d a n��mpl ante with ate to the best ll Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene TVDe of License: Title Plumber Signature of cense Plumber or Gas Gasfitter Cit�r/Town Master License Number _3%4'S nrYVED (OFFICE U _ O Journeyman f.7 l� 0 a W m 0 z F- r LL N !- Q J C7 z O O O N � r Wcc~ U � U. O W O z a a cc O o U. LL 3 z 0 O J r W Q m U J 0. a Q W W LL ' f.7 l� 0 a W m