HomeMy WebLinkAboutMiscellaneous - 225 MARBLERIDGE ROAD 4/30/2018 ��/'1�9���DG2 J'i D - 2.�?S
�---- _ - -- - - - ---i
.�
t7 6� 1 lS Date..
MORTIy
Of ,4,
3� TOWN OF NORTH ANDOVER
O A
•I.-
X PERMIT FOR GAS INSTALLATION
y
�9SSACMUSEtt
f This certifies that
has permission for gas installation . . . . . ..0v. . . . . . . . . . . . . . . . .
in the buildings of . . . . . . f.O X. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a . . . . n?.5 . . �� .C: .G . .���; North Andover, Mass.
i.
Fee��: S.D. . Lic. No.fI.�?d.� . . . . . .�� �� �• •
u20GAS INSPECTOR
Check# / 3(0 y
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
Date: Permit#f
City/Town:.------
Building Locatic_! a&5 _Ma'r iolc— Kdqe- e,.,C,)Clc( i Owners Name:
Type of Occupancy: Commercial Educational: z IndustrialF
_j InstitutionalResidential
New: J, Alteration: Renovation.' Replacement: Yes Plans Submitted: No�
FIXTURES
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0 5 LL < X 0 W W >0
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SUB BSMT.
BASEMENT
15T FLOOR
2 N
L'FLOOR
3KuFLOOR
-W" FLOOR
5THFLOOR
-i'FLOOR
7 THFLOOR
81"FLOOR
Check One Only Certificate#
Installing Company Name: Stark&Cronk Plumbing, Inc
I Corporation 2486C
Address::308 Main Street 'Cityffown:,'4 Groveland State:
-M-Aj r.
Partnership
Business Tel: ;978-372-6981 i Fax: -6-7--8 374 0837 -------
JFirm/Company,
Name of Licensed Plumber/Gas Fitter:1-13?m-
INSURANCE COVERAGE: - F-
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yej'-�No[_j
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 I 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 I Agent
Signature of Owner or Owner's Agent L-1
By checking this box E];I hereby certify that all of the details and Information I have sub olftRd(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and install p 4" ns perforNedl under the permit Issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumb(g 01 d and Ch
!)t!��the General Laws.
Type of License: --------
Plumber
Title Gas Fitter
"Sign ure of Licensed Plumber/Gas Fitter
Master
Journeyman
CityfTown,,,___ __,. License Number: 11027 p
LP Installer
APPROVED(OFFICE USE ONLY)
FINAL INSPECTION BELOW FOR OFFICE USE ONLY PROGRESS INSPECTIONS)
FEE: $ PERMIT#
APPLICATION FOR PERMIT TO DO GAS FITTING
NAME&TYPE OF BUILDING
LOCATION OF BUILDING
SKETCH
PLUMBER,GASFITTER,LP INSTALLER
LICENSE NUMBER:
PERMIT GRANTED❑ DATE:
GAS FITTING INSPECTIOR
i
Date-47
".ORT TOWN OF NORTH AN ER
3? �� r •..;• oL
I- PERMIT FO UMBING
o.�•`t9
�,SSACNUS�
S
,.
This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
has permission to perform . eta=�' .. ? . . . . . .
plumbing in the buildings of . . . . .
at- -1Andover, Mass.
Lic. No.
(/ PLUMBI G INSPECTOR
Check y
6971
i
o� MASSACHUSETTS UNIFORM'APPLICATION FOR PERMIT TO DO PLUMEtNt v
-\ (Print or Type)
Mass. Date S 0 14tPermit #
Building Location_ o;?s /z? I /gl�/t -- Owners Name ./���(
Type of Occupancy_
New 0 Renovation ❑ Replacement Plans Submitted: Yes O No O
B.P.# SEWER# FIXTURESSEPTIC#
.n zx a
r- m `a (A o z t- u
'+r Y y �- v a' z 14
H = N < a: a Z Q d1
4.3
J N W y so Z Q 1- t) W N Y < N 0. Z d. w 0. K
cc W o < H 0: 3 d Z O < N Z a 0. O 44
1.- V < YA 4J
z T Y 0. ix AO W O N. ) $1
Y m vl D J a s J J < 0: GC a 4 C 4).
SUB—BS MT.
BASEMENT
1ST FLOOR
2NO FLOOR
Y
3RD FLOOR
4TH FLOOR �...
5TH FLOOR
6TH FLOOR a-. ;, ,•,: x
TTH FLOOR
8TH FLOOR
installing ;
Company Name nFMFRC Pi�T C` r h+-
g._ Check one: ' Certincate #
Ac1dress P.O. BOX 88 Lt§ CorporationUPTITTEN, MASS
-21'44C
Partnership
Business Telephone t g 1£i-U3,-3_9 7 5 5 0 hmilCo.
Name of Lleensed Plumber _...
.. ....... _ __. DEMERS
INSURANCE COVERAGE:
1 have a current liability Insurance policy Or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes j7 No ❑
If you have checked ves. please indicate the type coverage by checking the appropriate box
A liability insurance policy IT Other type of indemnity El Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Z: per 142 of the Mass. General Laws, and that my signature on this permit
application waives this requirement.
Check One:
iignature of Owner or Owner's/bent Owner,
Q Agent❑
hereby certify that all of the details and information I have submitted(or entered)in above
nowledge and that all plumbing work and installations performed un the application are true and accurate to the best of my;
eminent provisions of the Massachusetts State in permit issued for this application wilt be in compliance with an
9 p 142 of the General Laws.
Y
tue gnature of n um r
itY/Town Type of License: Master[ Journeyman 0
A
Locations
NS"
No. � /
Date 3`'
NORTH TOWN OF NORTH ANDOVER
:•'M
10
9
Certificate of Occupancy $
asAcNuE<� Building/Frame Permit Fee $
s
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #. z4�
`
�'--
15499 —Building Inspect®r/
i
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE,.OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/I for of Buildingso `?�
SECTION 1-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
37p
, Map Numbea• Parcel umber
l.3 Zoning Information: 1.4 .Property Dimensions:
Zoning District Pr Use Lot Area Frontage 11
1.6 BUILDING SETBACKS ft
Front Yard Side Yard . Rear Yard
Required Provide R:', .red Provided Recpfired, ProvWd
1.7 water supply M.C.LC.4o. 54) 1.5. Flood Zone Information: 1.8 sewerage Disposal system:
Public ❑ Private ❑ zone Outside Flood Zone .❑ Municipal ❑ Onsite Dispose( system ❑
SECTION 2 PROPERTY OWNERSHII'/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) Address for Service
co o ov 9-c 0,
Signature Telephone
2.2• ftp >,ori2 t yr%
.3`-! -C'Q-Q,(1
NPrint Address for Service:
w„ \) �50@ 15 6-bb$b \AA kt C-
Signature Telephone. :
SECTION 3-CONSTRUCTION SER"V7CES
3.1 Licensed Construction Supervisor: Not Applicable ❑
r i
Licensed Construction Supervisor: x
t
License Number
h _ :µ
Address 4,. ••. -
__ _ Expiration Date
Signature Telephone'
3.2 Registered Home Improvement Contractor Not Applicable ❑
Company Name 4 � �Zb � 43
t C aC Qnw 6 n �A` \ „ � �a. Registration Number
3'
A s
,.Q J� '� b Expiration Date
Signature Telephone
SECTION 4-WORKERS COMPENSATION
(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
j in the denial of the issuance of the buildin rmit.
Signed affidavit Attached Yes.......6K No.......❑
SECTION 5 Description of Pro sed Work check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑
Accessory Bldg. ❑ Demolition .
them ❑ tfy
f
Brief Description of Proposed Work:
UJ r\J Ow S n o --cru C I ra
c_l,�na es
r0 — O .36)
SECTION 6-1 ESTMIATE.P.C€NTST CT,1`ON�COSTS ' _ •t
Item Estimated Cost(Dollar)to be n"
Completed by t a licant: t
L Building1 Multi lg T
g 2 SHO
O • (a) Buticlm Permit Fee
d
2 Electrical (b) Estimated Total-'Cost of
6's..
ConstrualOn
3 Plumbing Building Permit fee(a)x(b)
4 Mechanical AC
5 Fire Protection
6 Total 1+2+3+4+5 y Check Nuthber. .
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,
I, as Owner/Authorized Agent of subject property
Hereby authorize - to act on
My behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7bOWNER/AU\TI ORIZ1ED AGENT DECLARATION
as Owner/Authorized Ageni of subject
property' -I
Herebv.Aeclare that the statements and information on the foregoing application are true and accurate,to the best of myknowledge
and belief
Pte` y •2.r��"� .
Print N
LqZS 0 Z
Signature of Owner/Agent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB y
SIZE OF FLOOR TRABERS 1 sr 2 3
SPAN
DEMENSIONS OF SILLS
DIlMIENSIONS OF POSTS
DMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
tNORTH
ON0 over
VFW
o�A No. Z(P/
Co�„,� L dover, Mass.,•
�RATEO
S H �
BOARD OF HEALTH
PERMIT Food/Kitchen
Septic System
BUILDING INSRECTOR
THIS CERTIFIES THA ............................................. ..............0
.......................................................................... .................... Foundation
has permission to erect........................................ buildings on C�07 ... .. ...... .................................... . ..... . Rough
to be occupied a Chimney
p'
provided that the persona epting this permit shall in every respect�conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Final
UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR
Rough
. ........................................... Service
B LDING INSPECTOR
Final
Occupancy Permit Required t0 Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
Smoke Det.
SEE REVERSE SIDE
TOWN OF NORTH ANDOVER F Noack
Office of the Building Departinent �r°•;� "+,dao
Community Developmentand Services
27 Charles Street #V.
Cp bhp
North Anndover,Massachusetts 01.845
w
3 3gSs�0-2. S
D. RobertNicetta, Telephone(978)688-95-545
Building commissionerI
FAX(978)f;$8_9j42
DEBRIS DISPOSAL FORM
In accordance yvith. the proylsions of MAGIL c 40-s-54; and as�a-'.and tion of
building permit# the debris resulting from the work shall be
disposed of in a properly licensed.solid waste disposal facility as defined by MGL c
11, s 150a.
The debris will be disposed of at/in: QAzsh
M G
(Sit)e location)
Signature of permit applicant Date
Michael McGuire,Local Building Inspector James Decola,EkClMal Inspector James Diow,Gas/Plumbing Inspector
` The Commonwealth of Massachusetts
a Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers'Compensation Insurance Affl-davit
_.. Please Print
Name: v
Location: S M ax tu-Jap
Ci (1 OV 0,
Pho 09
am a homeowner performing all work myself.
01 am a sole proprietor and have no one working in any capacity
I am an employer providing workers'compensation for my employees working on this 'ob.
1
Com an name: �. �Q(Y�Q_.. � U 1 jr C.
Address 3WO
C A G A ' Phone t 65 51 Z
Ins
nce Co. ►t' �n� .
Cctm>�anv name: -
Address
City: Phone#-
Insimnce.Co. Potic r#
allure,to secure,coverage as requires}.under Semon 25A or MCL 152 can laact to the.
and/or one yearis'bvrisOnfnent as wen as civil penalties in the.fam of a STOP'WORK�EI2 and a -��a�5��to$1,SOb.00
understand that a copy of this statement may be forwarded to the Office of!n � 1 ay against me. i
of the DIA for coverage.verification.
I do herby certify n the pains and a#ies of perjury that the Worrrratim provided above is troe and correct
Signature M.v
\ ' nate OZ..
TV
Tint name ��� 4� Phone# 5() - 6
� 8
6
fficial use only do not write in this area to be completed b
pi y city or town official'
[]Check if immediate response s requied BuildingDept E] Building Dept
P ❑ Licensing Board
xrtectQ Selectrman's office,
person: Phone#. ❑ l lealth Department
Other
RKMAY'S COMPENSATION
325 "") Date. . j: .��.. ..:'....
r
f
,40RT#q TOWN OF NORTH ANDOVER
a Df�.,,r o ,•1't'O
3` °• • PERMIT FOR GAS INSTALLATION
' A
s
SA US
A
This certifies that . ., j. . . . . . . . . . . . . . . . . . . . . . . . . . .a
has permission for gas installation
in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . , North Andover, Mass.
Fee. . tj:>. Lic. No.. : . . . . . . . .. . . . . . . . N
GAS INSPECTOR
WHITE:Applicant CANARY:Building Dept. PINK:Treasurer
MASSACHUSETTS-UNIFORM APPLICATION FOR PERMIT TO DO GASFUTING
gYmt or Type)
✓� C!/ ' . Mass. Date" 19 Permit tt J 4_-J -3
U%p Bu)ldkV Location D?c� � /� I�Q G����I�irrfr�r's Name )7-0 X
Type of Occupancy
—2
New ® Renovation ❑ Replacement p--' Plans Submitted: Yeso No I0,
10W on
ac r sr
Mqp. W ~ 0 m 11-
Z
z O W h < z 9 0
< C1 W h y W O d C W
A4 W < h tt1 >
RC n rW y J h z W W O C ! L. h W J
< w a W < < 0 0 W O p
tl J V ¢ V G s F O
Sue— T.
BASEMENT
!ST FLOOR
2N0 FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
TTH FLOOR
STH FLOOR
Installing Company Name ��'t �/C Check one: Certificate
Address �TtporatJon
J) a/ Q/ ❑ Partnership
Business Telephone �S— ❑ Firm/Co.
Name of Licensed Plumber or Gas Fltterg�'z
INSURANCE COVERAGE:
I have a current -InsuranQ")olicv or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes W No
If you have checked y_es. please indicate the type coverage by checking the appropriate box
A liability insurance policyOther 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.
CheoK one:
OwneEO Agent ❑
Signature of Owner or Owner's Agent
1 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 the ppeermit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter.142ot._tt�e _neral Laws.
By T of se
umber Signa ure of Ucensed umber or Gas Fitter
Title
Location
No. Daile
N�RTM TOWN OF NORTH ANDOVER
Certificate of Occupancy $
' Building/Frame Permit Fee $
�'��°',•°•'t�' Foundation Permit Fee $
sswcMust a�
Other Permit Fee,4y. $ S '^
Sewer Connection Fee $
Water Connection Fee $
TOTAL $ f
�,` l-kv
— Building I ctor
08/10/98 09:57 00 PAID
12736 Div. Public Works
Location 1
No.' t Date
N
NORTH TOWN OF NORTH ANDOVER
F?,• • O.
Certificate of Occupancy $
` Building/Frame Permit Fee $
i i #
,yob •'<�' Foundation Permit Fee $
Ss�cMust
Other Permit Fee $ .-
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
!,
Building Inspector
V'
08/10/98 09:57 25.0 PRIO
Div. Public Works
PERMIT fVO. AI'I'LICATION I+OIZ I'ERMIT' TO 13UILl)********NOIZTII ANI)OVEIZ, MA
�( LOF.NO. 2. RECORDOFO\\'NERSIIIP DATE BOOK PAGE
At%I,No . (�Uv
Z.(V'E SU8 1)I\'. LOT NO.
1-0( A I ION 4 _ �� pt OF 13011 DING " c
NO.OFSIORILS SIZE
OWNER'S NAME i1+
O\VNP.R'S ADDRESS V BASENIEKT OR SLAB
RD
AR(I It 1 ECT'S NAME SIZE OF FLOOR TIMBERS 1 ST 2 ND 3
Bl III DER'S N.MIE >i . / SPAN
DISI ANC E TO NEAREST BUILDING H! DIMENSIONS Oh SILLS
DIMENSIONS OF POST S
DIS FANCE FROM S'TREE 1
DISI ANCE FROI\I I.OT LINES-SIDES REAR DIMENSIONS OF GIRDERS
AREA OP LOT
FR(NJ I'AGE I IEIGI IT of:FO(INDATION TI IICKNESS
SIZE OF I O()I INC, X
P13
NEW
MATERIAL OF CI IIMNEY
ADDITION)ALTERATI(NJ IS BUII.DIN(i( d SOLID OR FI(LED LAND
NGCONFCxtM TOREQl31REMENI S OF CODE IS dIIILDING CONNL'CTED'IO TOWN WATER
PEALS ACTION,IF ANY IS BUILDINGC(NJNECIED toIOWNSEWER
IS BUILDING CONNECT LD TO NA IT1RA1.GAS LINE
LAND COST
INSTII("PIONS 3. P1j(1PEWIN INFORMATION IX /
EST. BI. i.COS! (�
PAGE I FILI.CAITSECTIONS 1-3 EST. BLDG.COS IVLRSo .PT.
ES 1. BLIXi.COS I VER R(Oh(
ELECTRIC METERS MUST BE ON OUT OF BOLI IN NG SEI'1TC PERh11 I NO.
AFIACI IED GARAGES MUST C(N FC)RMTOSFATEFIRERE(iIILAII(NdS 4. API'RO\'ED BY:
PLANS MUST BE FILEDANDAPPR OVED BY BUILDING INSPECFOR BUILDING INSPECTOR
DAIS FII ED322, OWNERS Tf:1.H
C(NJI R.IEI/I
COtJTR.I.I(II 61J /,2rz
"SIGN AI'IIRF(-A-'OWtIOR IIORIZ1:1)AG NT
FI:I.
PERMIT GRAN IIID
19
l ✓y�e{'dlnnY�M.�y(LGL(14P.��4 , i
I. HOME IMPROVEMENT CONTRACTOR_.
I.
Registration 117436
i Type - OBA
1 'Expifa.tion 10/03/98
ALL, UNDER ONE ROOF-PEST IN PE.
0 MAN GAY
0 JFFFERSON'ST
�R ADMINISTRATOR
NOR;H,ANDOVER;MA 01845 �
p
DEPARTNINT OF PUBLIC SAFETY
CONSTRUCTION SUPERVISOR LICENSE
Nu0 -:Expires: Birthdate:
CS` C,342011-19130/1999 09/3011945
Restrictec
5 -r
NORMAN GAY
v 70 JEFFERSON 4ST
N ANDOVER, MA 81845
�-
pTown of
L
No.
z ; _ �•/a 199p
: ..
dower, Mass.,
-�O9 CLAKE
OCNICM WICK
A�AA E DP`y
tS BOARD OF HEALTH
Food/Kitchen
FE 177 '.., t' D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT...... .....................................................................................................a.......:...:.
Foundation
has permission to ere ................'..o............... buildings on . :': .. Rough
to be occupied aS
Chimney
provided that the person accepti this dermit shall in every respect conform to the.terms of the application on file in Final
this office, and to the provision of the Codes and By-Laws relating to the Inspection, Alteration and Construction of
Buildings in the Town of North Andover. PLUMBING INSPECTOR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
Final
PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUCTIARTS; Rough
.. .............................
............... Service
...................... ......... ..... .......
BUILDING SPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
gh
Display in a Conspicuous Place on the Premises — Do Not Remove Fnal
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector.
Burner
Street No.
Smoke Det.
- . r
. . .
Date.. ., . .
NppTM i
3 TOWN OF NORTH ANDOVER
' PERMIT FOR GAS INSTALLATION s
9SgAC IN4 e
This certifies that ._ : . . . . . . . . . . . . . . . . . r
has permission for gas installation . . . . . • . .
in-the buildings of .'-` . . . . . . . .
at . . . . . . . . . . . . . . . . . P � ;`�lorth Andover, Mass.
Fee . . . Lic. No.�/6/. !. . ZA
. . . . . . .. . . . . .INSPy,,,Lt-&p
Check#
5581
2 o ,----
� MASSAC14USETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Psi t or Type)
, Mass. Date 7 t6j=- Permit
Building Location (5?11? � �/ �/� Owner's Name �6)(
Type of Occupancy-G✓/'/�/j��'
New ❑ Renovation ❑ Replacement
Plans Submitted: Yesp No ❑
rn
ha
u m
sn H U
U1 Q W CC O j N x
W W h a: 0 U pl t^ X 71
UJ O U F- 'r O �• .0 h- yaj
�t t:
W m w -( :u ur O 0.
vice X C d 4
N 4r W Z 7: 1.. W 0 > W
vz x s -s m O e `'' r-' "' v X vl ' ae
"' H E- a"r- rn m > o x w c z
cc 'X O 0 Y IL 7 # O 0 J 0 > q d � O
SUB-8$MT.
BASEMENT
f ST FLOon
2110 FLOOR
3RD FLOOR
4T11 FLOOR
STH FLOOR
aTlt FLOOR
7TH FLOOr1
BTNFLOOn FFIJ
Installing Company Name T)eenere pl hq_ & Htcr. Inc- Check one: Certificate #
Address_. p0 'lox,—tib 0 Corporation
�•--- met bue n, MA 01844 p Partnership
Buslness Telephone6A1_g75-5 _ O Flim/Co.
v Name of Licensed Plumber or Gas Fitter nQ„a i neMer.G
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ® No O
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy ic7 Other type of Indemnity O Bond ❑
OWNER'S INSURANCE WAIVER: ( 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:
Owner❑ Agent O
Signalure of owner or Owners Agent
1 hereby certify that all of the details and infoanation 1 have submitted(or entered)In above application are true and accurate to the best of my
knowledge and that aq plumbing work and Installations performed under the.pormil issued far IN plicatlon wtli be In compliance with art
Pectin provisions of the Massachusetts State Gas Code and Chaplet 142 of th ,8103,
T e of License:
Plumberlure a Liconsed Plumber at Gas !er
Title Gaslittor
Cil /ToMrn Master Uconso Number 9142
t,ft'(1r)MCn�TI'tC'_ r) ioulncyman
it