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HomeMy WebLinkAboutMiscellaneous - 23 UNION STREET 4/30/2018N �O O w { Z 1 N Z m o � { i .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .PA -t 1 C . ...-...!...:!.................................................................. has permission for gas installation :7�zs..................................... . inthe buildin s of......lv...C.............................................Q.r...'................................................................................. at ........-�.....�-�...... r-!!�"� ..........{. North Andover, Mass. o� Fee .�.5...::" ...... Lic. No. I� 0F1'2> M.��rr..............:....................................... GASINSPECTOR Check # r, . Mu I1 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATES-L-PERMIT# JOBSITE ADDRESS S'i- OWNER'S NAME1 GOWNER ADDRESSC)c>>G T r TE TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL" IT CLEARLY NEW: Q . RENOVATION:A REPLACEMENT: PLANS SUBMITTED: YES 0 NOD APPLIANCES 7FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ .,. (� 1. . BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER mill DRYER FIREPLACEFRYOLATOR FURNACE GENERATOR GRILLE '�— INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST--I�--� -J - - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER j INSURANCE COVERAGE, I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 6 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ( LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND F] OWNER'S INSURANCE WAIVER: I am aware that the ensee 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 ED SIGNATURE OF OWNER OR AGENT 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 co m i ce ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME'"�Q_t t�-_h)� LICENSE # 3JI SIGNATURE LPGI CORPORATION ®# Z�Z PARTNERSHIP E #© LLC E]# Mf MGF [A JP ® JGF 0 I .:.r.:J! LL COMPANY NAME: 7 ADDRESS 2?% CITY _ STATE ZIP TEL i FAXCELL EMAIL i{ ` The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r1 — p Please Print Legibly Name (Business/Organization/Individual): h6l�D I , ��Ur"'U��� qpm Address: `:'ZZ AAA tiJ Q City/State/Zip ,P0 C* PjLJ 6 �c(`� Phone #: Are you an employer? Check the appropriate box: JrI am a employer with 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. I ship and'haveno 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.❑ Electrical repairs or additions 11.❑ 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. I 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name: _ Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 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. I do hereby cer/I u/n//�f]er izz�/Jpainns/l(J/�j(d penalties ofperjury that the information provided above is jtrruu/)e and correct. 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 retained 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 permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) 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 Intvestiga}t1ou 600 Washington Street Boston} MA 02111 TeX, # 617-727-4900 ext 446 or 1-8777MASSAFE Revised 5-26-05 Fax # 61.7-727-7749 wwwanass.gov/dia Division of Professional Licensure: License Search • The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE 1 Name:DAVID M. QUIGLEY Business: BROTHERS PLUMBING, HEATING AND A/C INC METHUEN,MA ..This Licensee has additional Licenses, click here to view them.** Licensing Board: PLUMBERS £t GASFITTERS License Type: PLUMBING CORPORATION License Number: 2828 Status: LAPSED Expiration Date: 5/1/2014 Issue Date: 12/14/2006 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Thursday, May 08, 2014 at 3:06:49 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_code=PL&type class=_C&Iic... 5/8/2014 v %f 9876, Date .... .......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... ...... C'�z ... C ..... has permission to perform ....... Aivp .. 6L ... k !F wiring in the building of ....... W ...... AISPAy ............................................... at....,:)3.-.?eS ..... ARn-Z .......ST. ............... North Andover, Mass. Fee.. Lic. No. .............. wwl'4 .4 . .............. ��C-4' Check -7 r C..OAItAlOt7iUO�l{Ii P��Q'Q4K�Itdmii� .1°1e1oarasirsart� P��it �trwiud BOARD OF FIRE 'PREVENTION REGULATIONS Oflicicd Use Only Permit No. �Q Occupancy and Fee Checked [Rey, 11/991 �_ ve blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work Io be perfornud in accorJaauc with the MLswIlusetts ElLctriaal Code (tvt[C) 527 CIyR 12,00 (PLC'sc Plt11Vl'1N.11vK OR I i'1'1'.dLL ltyront,,vo1Vj Date: City or Town of: _OVIG/? 13y this application One ultdrrsiSnd gives notice of lis or her intention to perform tineelectrical Ille work described bclo.,v, _ Location (Street & Nuneber)_ ��n1 O f7 S Owner or Teilant /t c. Owner's Address Telephone No. - q =9UOy 1s this permit 1l, conjunction will, a buildiia per,slit" lees No— Purpose of uuilrihsg_�_ (Check Appropria(c nos) Utility Authortxalion No, E xistittg Scl•Yicc �— Ampi — I _\colts Overhead Ue10rd g 0 No. of Alclers cw rA•'cc _ Anips rai } Volts Overhead � r� 11 No, ofl4leters Number of Feeders and Ampacite� Unrl>it✓t.aL ''f�Li7l JJF - 2 :s-4 -?is-, 1.0c2ttun and Nature of Proposed Electrical � ork: -114- �-_-__ No. Of Recessed i'lxturc3 `7N'u. wrn� t.rwr ar r:re�arr.Jwerrp fif Ceii -5usp. (Puddle) Fans a2 ravre msvv Lw:' u'Q(Ydrt QY tIlC IqJ rtOr Of t t�ire8, O' O ��� 'Tralnsfar:hers KVA ` O. of Lighting Outlets No. of llul Tubs Sgvilllti,ll,$ POUT Ove seQnnerny nd. rnd. 0 Generators XVA No, of Lighting Fixtures � tg1 n 8at1e Utits No. of Receptacle Outlets � No. of tail Burners VIRE ALARMS No.. of Zones �.. No.. of switches _ No. of Gas Burners a. oDetection nd 1111tiatianp Devices _.. No. of Ranges No. of Air Cond. Tons No. of Alerting Devices ~ 'ROK :No. of Waste Disposf s eat ump TolsJx: -wunl. er ons _ ` o e onta ne F3etfsctiatl/A➢arrtin Devises No. of Dishwashers No. of Llryers Space/Area Heatlt►g KW Heating Appliances Key Local Connection Other ecurtty yotellis: No. of Devices or Ettulvaleat _ t o� orW teer Hl`r Henters t o, o '190. o Sittis Ballasts D2t:, !Violet No. of vices or E�nrulv�alent _ No. Nydronlassa e)Batletulrs _ into. ref Motors TotalUPc _i ccommuct catTanstl'ir�g No. of Devices or E_quivaltnt OTHER: sme/ 'r Arracn anatcra.ra# aerurr Y aearrra, ar as rrqurrea UT "Ic rnspccrur o/ rr RAret s. INSUNCE COVERAGE: Unless waived by the owner, ticpermit for the performance of electrical work may issue, unless, the licensee provides proof of Iiibili+y ius,atsnu inel,Idiu_a "completed operations" coverage or its substantial equivalent. The undersigned certifies that sntch coverage is in force, and has exhibited proof of same to Elie permit issuing office. CHECKONE: INI SURANCE � :3018D ❑. OTMER 0 (Spccify:)��/ o iid?f�[ fife, /I/a/11 (E�ipr7atto Danc) Estimated Value of Electrical )Fort:: �QpQ, O/ (when required by municipal policy-) Wort: to Start: 113/// Inspections to be requested in accordance with IVIEC Rule 10, and upon cotnpietion. 1 Certi y, under the pains and pernalo.;cs ojperjtrry, thrat the infor»tation Qat dais applicativrr 4 true void complete. i t?11281 NAME. AXV�( tc t'1 'QIP/G� . ___ __ _.._._ LIC. NO.:, TOS Licensee: �/1t4NU$ _��� 5lgtaatw c LIC. NO.: _ (t/'ttpplicable• carter `•a empt " in the licctrte number lino. • Bus. Tel Na,'��(q ��� Adds -ow, & triYe .._ �t 1"q— a r Alt. Tei. No -.V: �-6_lr?�: r 3 �.. o �" - ONVN£R'S Ii�SURANC. 1tA1VER: I un i aware tlsat the Licelsxe: Ott not /tG,w[ tltC liability insurance co'verage'normally required by last•. By my signature below, I hereby waivc this requirenicstt. I vin the (chcck otic) 11owltcr ❑ owncr's agent. Owncr/Agcsst Telephone No. PesRuir 1�'E .: S Signature - - - -- -- ----------�- p - - - ____ . _ 5 a.i . a i 1 t I Date .... f /.�.77. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... /..1/kO !/G has permission to perform ....... wiring in the building of 9. ................................................... at ..........,?..�'2 S.. !t/�f� /..../..................- , North Andover, Mass. O Fee ...... ...!%r -"' Lic. Nob ! ELECTRICAL INSPECT7/ Check # 9U5) a �nmarsonw046-PIM49e44welb .. 0pai,bn", n jJira s rvi.s BOARD OF FIRE I R.EVENTIOV REGULATIONS Permit No. Trey and Pee CheckedRev.m 1 1 l 1/ /99) lcuvs t:tar►Ic) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK (PLC.ISCAll work to be performed in aeeotJut►re with the klulmhuscus Electrical Code 0"C- )• 527 Chit, 12.00 P/t1N"r IN INK OR TYlaEALL liVFOR,&tg7/ON) Dote: City or Town of: � ivvR� 41U D6VreMe"�-- ✓O 0 � By this application the uuclersigated gi+'es notice of lits or her irttentiotnto rpe�ri� i b� electrical r of k described below, r Lorratiun (Street & Number) ����',.� Urj � 0,7 �� Owner or Terrattl Owner's Address --1�1 . �.,. ___ _. Telephone No -W 9004 1s this permit in conjunction ►vitlt a t3elildin2 l:trurit" Yes 19 Nu��~ l.. .1 (Check A) ro rinse 801)W Purpose of uuiIding - _ Utility Autlseriaantivst No. ' 6"5— Exfsti»g Service _IPO Amps /tfJiy0 %,oils Overhead i0 Uratl ral �^p �•icc ZS AnY l..J � No. of A•Ycicrs .� cw r �., slis M / p 1 alts Overheadiittdgrcl ❑ No, orMe4ers .3 d�C Number of Feedcrs and Ampacity f Location and Nature of Proposed Electrical Work: L, /_e:a #5L_d/ No. of Recessed lrixtures �s�+u. wrr pr�.sw( vI rrK)Vri ilYl_ 1r L! of Ceii -Susp. (Puddle) !F<'aa" Ioule may til'1, p'a()�el by fE�e 1,11V14647t9�` oitt�lrFt. a• o o rransforaaaers XVA No. of Lighting Outlets No. tit l lot Tugs Strininsing Poul Above ❑ ti- 13 Generators KVA o. o`i s acne. g a sag No, of Lighting Fixtures- trod, artsd. BatteEx Units No. of Receptacle outletsS No. of Oil Burners FIRE ALARNIS No. of Zones No. of S►vitches J No. of Cas Burmers _ _ ` o, a eteetion an —'" 111Itiat;ng Devices No. of Ranges / _ 1`l0.- of Air Conti. oral Tons No. of Alerting Devices .�. g ofVaste )Ispoe3 eat unip unI e1 Totals: ons No, o c onta ticNo, DetectiomiAllertlar Devices of Yislnastacrs Space/Area Heating K�V � un cipaTNo. Local 0 Connectloli 0 Other Heating Appllancos ecttrs4y ysterns: No. orlJrycrs % w K1V No. of Devices or Equivateat IN c1� oTNV a"Ser KIN, s o. o r 140. of Data Wiring: 1leatcs's Siytns Ballasts No. orevices orrEE uiivvolent _ �io..liigdrontassageBattitvbs No. or Motors TotallrlP c ccontniucsTatTa`ns�i'iaiti�,: "�r``" No. ofyev Iees or Equh'aletrt OTHER: ntrocn aaasrro+tat aerau y o:esirea, or as requtrea oy me m5peetor oj +rrres. INSURANCE COVERAGE' Unless waivtd by the owner, no permit for tbo performance of tlectricut .work may issue unless, tl;c licensee provides proof of liabthty insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that stick coverage is in force, and has exhibited proof of same to Flit permit issuing office. CHECK ONE: ii�SURANCE L 30,81D ❑. 011-1ER ❑ (Slsccify:) _f- fK 91 AJ ( I_Y/ (Etwira con Date) Estimated Value of Electrical V%!ork: (When required by municipal polic; .) Work to Start; o'5-09 lntpections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepabts and prnalt•'cs DO Privr,•, that thefnfortsaallon nig this appl;catfvrt is trite and eonsplere. --- IF NAI M. _ fi /y -l2i ca 1 s ✓�c, LTC. No.: LIC. NO.. 50 58$ Licensee: , GrS�jfSignatuic_ , - fif applicoble. ar�tay _ ¢clot t " in t c Fre Vit it sh r IMe')�� Bus. Tel. No.: Address: r r.��+ _ _ All. Tei. No., � O'WNER'S INSURANCE WAIVER- I atn atvare III -at the Licensee does not have the liability insurance coverage normally required by liw. 13y my signaturc below, I hereby waive this recluirement. I arts the (check onc) 0 owner aWttcr's agtrsst- O►►'ttcriAgcut1'cic ItoaacNo. PtRIVU FLir': S 5igitatw•c _.....,�.�.�..._.. P N br 4 1 u . Q 1 TOWN OF NORTH ANDOVER Building Department 1600 Osgood Street Building 2- Suite 2-36 Building Dept North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: / � TEL #: / .. NAME OF COMPLAINTANT: ADDRESS, /i%e1'gido1( COMPLAINT TYPE: Electrical: Plumbing: Gas: `Building: Property Owner: Address: Other: e,4 L I -elt A //' a '�;? 3 — 1�2 S D� J' kd'e J�1 N'i't '- /t o E' ti , 7i is' Signed: I,<l i Gv Complaint Form - Revised 6.2007 TOWN OF NORTH ANDOVER a a Building Department o - 1600 Osgood Street Building 2- Suite 2-36 Building Dept"Ssa�wuse% North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: �'�-� �� TEL NAME OF COMPLAINTANT: Atld t,y `y UGfS 14Ilaly ADDRESS::...e,do COMPLAINT TYPE: Electrical: Plumbing: Gas: Building: Property Owner: Address: Other: /3 ,//r, L. dd l L-elt- .9 //ej es �l q 7'- -?3—.2-s- Y4 3--d2SY4 /Ilyc Signed: �A�iLy is �j�i,�f 2ti�� %QA. Complaint Form - Revised 6.2007 `�iva .epp,G�.P 736Date...1���' ........ . ° ~O or '` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r .y ./. /1.�. 1. .�!g �... . This certifies that .. /.f !'` ,�, g has permission for gas installation ....V �-/ ................ in the buildings of . . ............ . at ..... .......I. .......... North Andover, Mass. Fee. Z. J Lic. No..?3 ?.. �L!✓. ` •-� . . /GAS INSPECTOR Check # I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Z No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy °P 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 ❑ Sionature of Owner or Owner's Aaent By checking this box ❑; 1 hereby certify that all of the details and information 1 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 ChapterA429f the Ge�@ral laws? Type of License: By ❑ Plumber Tine ❑ Gas Fitter Signature of License lumber/Gas Oftgr ❑ Master City/Town �Ioumeyman License Number: APPRnVFn MFFICF USE nNL)n ❑ LP Installer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: 111469 d/,�L�f2 MA. Date: `ts to Permit# % 3'� O Building Location: :233 01 PM 5�f- Owners Name: 61-8 )FVGCZA? FIXTURES Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential (� New: 0 Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Z No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy °P 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 ❑ Sionature of Owner or Owner's Aaent By checking this box ❑; 1 hereby certify that all of the details and information 1 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 ChapterA429f the Ge�@ral laws? Type of License: By ❑ Plumber Tine ❑ Gas Fitter Signature of License lumber/Gas Oftgr ❑ Master City/Town �Ioumeyman License Number: APPRnVFn MFFICF USE nNL)n ❑ LP Installer FIXTURES vi Z Q Tinv Tin O = = M = O 1�_ W W O J> V M W H Z N O W X W W Z Z H w M Q W Z O m 0 W a ir O O O F - w X Tin > W Z W I- W W a O IW- Q W W o= x W > Q V W Z W O W W Z J H F J M= O Z J U' LL Tin H = Z W W I.- W W Z U >- C 0 LL (* Q Q 2 2 M W O O Z Oa 0 M HF >>> - O 1 1 SUB BSMT. BASEMENT 1 FLOOR 2 ND FLOOR 3 FLOOR 4 FLOOR --i'FLOOR 6TR FLOOR 7 -FLOOR 8 FLOOR Installing Company 14• 'w �'� Ct t`vl ' 1 I tJw� �` Check One Only Certificate # Name: >f q3 G �CWPiI' l s1. kt2. K4A �d4pi El Corporation Address: City/Town: State: ❑ Partnership Business Tel: '�] q t ^ v Su - 7 Z 30 Fax: IffFirmlCompany Name of Licensed Plumber/Gas Fitter: Mt I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 Yes Z No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy °P 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 ❑ Sionature of Owner or Owner's Aaent By checking this box ❑; 1 hereby certify that all of the details and information 1 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 ChapterA429f the Ge�@ral laws? Type of License: By ❑ Plumber Tine ❑ Gas Fitter Signature of License lumber/Gas Oftgr ❑ Master City/Town �Ioumeyman License Number: APPRnVFn MFFICF USE nNL)n ❑ LP Installer A NORTq +4, FO P ,SSACMUSEt This certifies that DateC�'/�/ G... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 5 ............. has permission to perform ... . * 11.`:. � ............. plumbing in the buildings of . 4 .� yH. Y ....................... at .. e�. 3.. ,k ! b. �-... ?? .......... , North Andover, Mass. Fee 4/f j ' 7? "-` Lie. No. 3/3.7.5 • ..... PLUMBING INS CTJR Check #�_ E661 FIXTURES MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: W0,611 AhAl t MA. Date: Permit# W51 Building Location: A3 on om Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residentiallu New: ® Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes,Z No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 1P 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 ❑ Signature of Owner or Owner's 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 Type of License: —e -1W Title ❑ Plumber Signature of Licensed Plumber Ci /Town ❑ Master APPROVED (OFFICE USE ONLY) City/Town License Number: �J DEDICATED SYSTEMS Cr LU z z u O uZi i WZtA Z ILLU } N J V 1� W Z 99 qZ W LU O ZLU VA W Z g g 4A N O a !� V) H Q H OJ Q z w O Q ce W Z H W J z V W d ,i CC x cis J W 3 a e i= a o 3 u z a U. 3 d Y z W o o Q> y � Q Q h LAO p a o o x �= > 5 > C 5 x O Q it a S 3 a 3 a 3 o u Q w °� a 3 m m e: a c� 4 SUB BSMT. BASEMENT 'I FLOOR ° FLOOR ° FLOOR E FLOOR 5 FLOOR 6 FLOOR r FLOOR FLOOR �n Check One Only Certificate # Installing Company Name: /1J I�" �i'W�1 11*7�f, jun n Address: `U YLK tO ity/Town• I�f State: ElCorporation ' ,��IIF'L1 El Partnership BusinessTel: 11V Fax: ❑Firm/Company Name of Licensed Plumber: "k(Aw)` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes,Z No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 1P 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 ❑ Signature of Owner or Owner's 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 Type of License: —e -1W Title ❑ Plumber Signature of Licensed Plumber Ci /Town ❑ Master APPROVED (OFFICE USE ONLY) City/Town License Number: �J