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HomeMy WebLinkAboutMiscellaneous - 24 PRESCOTT STREET 4/30/2018 (2)` 1 Date..��..'�� 5.`.1..`.�...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that....P! P1j/L C1L has permission for gas installation...........................:................�...�?.�............. in the buildings of ....... ........................... ........................ ... .................... .....��.'........................................ North Andover, orthAndover, Mass.at "1.......... .... Fee ..."...... Lic. NoRr��...... .M.�................................................. . GASINSPECTOR Check #-3 09887 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i'ERMIT JOBSITE ADDRESS a - e to 1 OWNER'S NAME Fc_a-ii...1�n&&Fd'Zgi• °tea OWNER ADDRESS TEL�IFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL Jr EDUCATIONAL [j RESIDENTIAL CLEARLY NEW: F—�. RENOVATION: D REPLACEMENT: [ `' PLANS SUBMITTED: YES © NO [ '" kPPLIANCES 7 FLOORS - 4 1 [ 2 _[ 3 [ 4 5 6 7 . 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER [ DRYER [ FIREPLACE [ FRYOLATOR' [ FURNACE GENERATOR j GRILLE INFRARED HEATER LAB ORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST -+ UNIT HEATER UNV'i,NTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES WO El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND 0 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 AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc totd a best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In cornwi IIP ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME �Daiy�o �c.cFi£Lo LICENSE# 156k SI NATURE MP DMGF 0 JP ® JGF QI LPG[ ® CORPORATION PARTNERSHIP Ob LC ®#'= COMPANY NAME: ee __ gro SEz,, _ ADDRESS — CITY �as-( _ _ ( STATE' /1'►/ -a ZIP Z I_Z2 TEL FAX CELL s°�rJd6-14QR EMAIL �yy 0 r ,» L \� \&F \T 7S ƒ , . / !Q H FOLLOW1 EN E,-, \\ \ R� /S {) A$ MB #© \ƒ\ . . yx #Av} W GARF4itD © ~ \ © ( . E8BROTHERS &(RVtCEt ƒ « , � 21. WI L + . . � 723. y. ^ 36 9 .\ `0 4t$ .. § t� FEENBRO.01 SMORAN 'AC--®AVA5P° --- CERTIFICATE OF LIABILITY INSURANCE DATIYYYI)-- 11130/20301201 b THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ifeu of such endorsement(s). PRODUCER Rogers & Gray Insurance Agency, Inc. 434 Rte 134ac South Dennis, MA 02660 CONTACT NAME: PHONE No Ext : Arc No : (877) 816-2156 ADDRESS: INSURERS AFFORDING COVERAGE NAIC 0 INSURERA:OId Republic General Insurance Corp.— 24139 02/0112015 INSURED INSURER B INSURERC: Feeney Brothers Services LLC 103 Clayton St PO BOX 220801 INSURER D: INSURER E: Dorchester, MA 02122 INSURER F • $ INOVAMUIXC;N N2CM 1171N-1119MNI V,1SI2: zl EL►/C9 r013111 31 a111 aldr THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTft TYPE OF INSURANCE D Dso SBR %IIVD POLICY NUMBER MMJDDYIYYI! RSOLI DIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR A2CGO7501501 02/0112015 02101/2016 EACH OCCURRENCE S 1,000,00 PREMISES Ea occurrence $ 300,00 MED EXP (Anyone person) $ 10,00 PERSONAL &ADV INJURY S 1,000,00 GEN LAGGREGATE LIMIT APPLIES PER: RPOUCYPqjEC QLOC OTHER: GENERALAGGREGATE S 2,000,00 PRODUCTS -COMPIOPAGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALLOVANEO SCHEDULED AUTOS AUTOS NON-MNED HIRED AUTOS AUTOS - COMBINED SINGLE LIMIT $ Ea aori4. BODILY INJURY (Per person) $ BODILY INJURY (Per $ ( ) PROPERTY DAMAGE Poraaide t $ $ UMBRELLA LIABOCCUR EXCESS LIAR HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ DEO I I RETENTIONS Is A WORKERS COMPENSATIONAER AND EMPLOYERS' LIABILITY YIN OFFICEOPRI. O"ARLUDE�ECUTNE (MandatcrylnNN) It yyes, describe under DESCRIPTIONOFOPERATIONS b0cN NIA 2CW07501501 02/0112015 02/01/2016 OTH- X STATUTE ER E.L. EACH ACCIDENT S 1,000,00 E.L. DISEASE -EA EMPLOYEE $ 1,000,00 E.L- DISEASE- POLICY LIMIT S 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Tow Osgood And ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 1. X , . ©1888-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) t The ACORD name and logo are registered marks of ACORD Date ... n..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ...................................... ........ ... This -certifies that ...... ,�as permission for gas installation ..................... + ...... f .in the b *ld* ....... ............. V2,?..e . ........................................................................... U, , so ...... ..... at.... Q .. ...... .................................................................... . North Andover, Mass. "Q �4M4Fee.G........... Lic. No. ........................ ................................................................... GASINSPECTOR Check # �2 -7 � I 09'888 r -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK T CITY -1-MA DATER (� JOBSITE ADDRESS OWNER'S NAME tJ OWNER ADDRESS TEL+�FAX TYPPEE OR OCCUPANCY TYPE COMMERCIAL �I] EDUCATIONAL RESIDENTIAL CT,EA,RLY NEW: Q RENOVATION: [ REPLACEMENT: }'' PLANS SUBMITTED: YES D Noa- APPLIANCES Z FI OORS—► BSM 1 2 —3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR INFRARED HEATER _ LAB ORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 0<0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Eg-�- OTHER TYPE INDEMNITY ® BOND 0 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 AGENT) " hereby certify that all of the details and information 1 have submitted or entered regarding this application are tru oci and that all plumbing work and installations performed under the permit issued for this application will be in co i c th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. v PLUMBER-GASFITTER NAME ��� ,�, £ LICENSE # 156 K MP [3,MGF 0 JP ® JGF d LPGI ® CORPORATION [2,f PARTN . SHIP ®#E COMPANY NAME: ee ro S�:zv c e� ADDRESS Lip.� CITY STATE' /►t ZIP 2 f Z Z TEL G/r FAX CELL .6-41 EMAILnneeN� Y 6ro�l�eaC . CO to AGENT Jsi of my, Knowie< provision of the } PLUABERS- 29 _' 4 $a ISSUES h k ASFI.TTE S, THS FOL`LOW,IIG�{ENS Lnl ElSErp A'S A �tAS�TPER pLfUhIBER '� GARFIEL@F� arr` F F MA p -�' aw Y 23 oa 564 p o,I / 16 2264.42 .gCQMM.ONWEALH,Oall -I F'MAS7HSETTS: *;»; PLUMBER`4A�Jbx G'ASF1TtER 1 E 3 ISSUES THE FOL LOW Id�]�C�IC�NE 3 REBI Slr 'RED A'S A PLUMB,I N 0 1 ' OAUTA 'W GARFII ELD ;E,ENE7 BROTHERS; SERVItiG<E, x 21 WPLLDW � T.' w 4 I OR6%6N , M>, 0230r �G"1 nG%01 i.1,6 22.1',4.13 FEENBRO.01 SMORAN ` 410"Rk y._.-..........----------- — - - CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 1/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTE=ND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pol(cy(tes) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Rogers & Gray Insurance Agency, Inc. 434 Rte 134 South Dennis, MA 02660 CONTACT NAME: PHONE FAX ac Na Ext): Arc No : (877 ) 816-2166 ADDRESS: INSURER(S) AFFORDING COVERAGE MAIC N A2CG07501601 ~' INSURER A:Old Republic General Insurance Corp, 24139 02/01/2016 INSURED INSURER B Feeney Brothers Services LLC 103 Clayton St PO Box 220801 INSURERC: INSURER D: INSURER E. Dorchester, MA 02122 INSURER F: $ (J)V!^RA14FS CFRTIFICATF 1Vl IMRFR' I0F11IQln 1 IJIIMRmo. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE D SBR POLICY NUMBER POLICY EFF rdhVDDIYYYY POLICY EXP MWDDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAN.IS-MADE a OCCUR A2CG07501601 ~' 02101/2015 02/01/2016 EACH OCCURRENCE S 1,000,00 PREMISES Ea occurrence $ 300,00 MED EXP (Any one person) $ 10,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY M JECT a LOC OTHER: GENERALAGGREGATE S 2,000,00 PRODUCTS - COMP/OP AGG S 2,000,00 $ AUTOMOBILE LIABILITYCOMBINED ANY AUTO AUTOS AUTOS LED N" -OWNED HIRED AUTOS AUTOS SINGLE LIMIT $ Ea accident BODILYINJURY (Per person)ALLOIA$ BODILYINJURY (Per accident) $' PROPERTY DAMAGE Per act de t $ $ UMBRELLA UABOCCUR EXCESS UAB CLAJI,18-?JADE EACH OCCURRENCE $ AGGREGATE $ DEC) I I RETENTION$WORKERS $ A ANDMPENSATION EMPLO CO YIN A FICER,RIETERPEACLUDE�ECUTNE FqNIA (MandatorylnNH) Ues, descnbe under SCRIPTIONOFOPERATIONS belon 2CW07501501 02/01/2015 02/01/2016 ER X STATUTE ERS E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE -EA EMPLOYEt $ 1,000,00 E.LDISEASE- POLICY LIMIT S 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) Town of North Andover 1600 Osgood Street North Andover, MA 01845 f ..C. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE X :'Q 1988-2014 ACORD CORPORATION. All rights reserved. -ACORD''26 (2014101) The ACORD name and logo are regl'stered marks of ACORD Date%?A7/`0* e) � TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .. `!!'.�� ���s1"� has permission to perforina'//1�?-�!-P wiring in the PbuZ 'ng of ... .............................. . at .. .........I (1. ......... . , North Andover, Maass. ' t......... Fee%! .... Lic. No S�G ELECTRICAL INSPE�CTO Check h �� 11313 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 �P g gh pp be filed Vv on the prescribed form. After a permit application has been accdPted 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 entitystated 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 puipose 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, 2008 and extendingthrough August 15, 2012. Rule ZI — Permit/Date Closed: _I ,4V/�%s� *** Dote: Reapply for new permi ❑ Permit Extension Act —Permit/Date Closed: Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 11 -� O Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 27 C 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: /7 A ld/ City or Town of: NORTH ANDOVER To the Inspec r of fres: By this application the undersigned givpsnotice of his or her intention to perform the electrical work described below. Location (Street & Number) S Owner or Tenant tj hp ,r Telephone No. &/ 7-34:4-300S— Owner's -,3/a-3G0GS— Owner's Address Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building`Utility Authorization No. Existing Service /ji0 Amps 1� Volts Overhead ffT Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: k,(�� Completion ofthe following 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 AboveIn- Swimming Pool rnd. ❑ rnd. ❑ o, o mergency ig ting 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 o. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers l Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No, of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or E uivalent OTHER: Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 and penalties ofperjury, that the information on this application is true and complete. FIRM NAME:. 4 sE 7� L i' `i LTC. NO.: Licensee: Si ature LIC. NO.:, --5-1Q3 / (If applicable, enter "exempt" in the license number line) Bus. Tel. No. - Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ fos- 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 �' 4 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 I electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the v! 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 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: a Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: u Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: f Inspectors Signature: Date: ROUGH SPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: I ' _ Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ . Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizati6n/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ Ipm a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ Ilam a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ 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.] i 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. F1 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. 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. am an emplayer that is providing workers' compensation insurance for my employees. Below is the policy and job site zformation. isurance Cgmpany Name: olicy # or Self -ins. Lic. #: Expiration Date: :)b Site Address: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. .lone #: 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 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 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 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-contractor(s) 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 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 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 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1.877-MASSAFE evised 5-26-05 Fax # 617-727-7749 www mace anv/dip 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 SEARCH CRITERIA Profession: Electrician License Number: 51031 NEW SEARCH LIC. LIC. TYPE LIC. NAME CITY/STATE LIC. BOARD NUMBER STATUS Journeyman Electrician ARTHUR J. NORTH ANDOVER, Electricians Electrician e Class E 51031 GUTHRIE MA Current Your search has resulted in 1 licenses The page above has been generated by the Division of Professional Licensure web server on Thursday, January 24, 2013 at 8:14:38 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License I.ocate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of license Status Codes More Site Policies Contact Us http:,Hlicense.reg. state.ma.us/public/pubLicRange.asp?profession=Electrician&licenseNo=... 1/24/2013 OF p10RT14 qti O 3� Oc s Date d d TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.0 !!A—j .e,S qLAW%. has permission for gas installation. co—OV- .. ��P ... , . . in the buildings of. ,,,, at ..2. .. er.� Gam.. .......... , North Andover, Mass. Fee 3A... Lic. No. 2,1.. . .1,14 ..................... GASINSPECTOR Check # 34;Ll 8567 1 GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY / L—, MA. DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME ADDRESS: TEL: FAX OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL �/ / NEW: ❑ RENOVATION: (� REPLACEMENT: E] PLANS SUBMITTED: YES ❑ NO ❑ '1 FIXUTRES 1 FLOOR— Bsmt 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES] NO ❑ If you have checked YES' please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE 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 AGENT hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTERNAME: Peter J Crane LICENSE# 21805 SIGNATURE COMPANYNAME: I Crane's Plumbing & Heating ADDRESS: 70 Douglas Street CITY: I Haverhill STATE: 11A ZIP: 01830 FAX TEL: 978.771.1155 1 CELL: 978.771.115 EMAIL: annacrana.ac@verizon.net MASTER ❑ JOURNEYMAN 0 LP INSTALLER ❑ CORPORATION ❑ #=PARTNERSHIP ❑ #® LLC ❑ # 2 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 11_7��—fi Address: City/State/Zip:. Phone #: ,� z e-, ,% ,;;ell /Z ,S�f kre you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I e}nployees (full and/or part-time).* have hired the sub -contractors [� 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 ❑ 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.] i 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. E] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ty applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. )meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. ntractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. ,n im employer that is providing workers' compensation insurance for my employees. Below is the policy and job site 2rmation. urance Company N icy # or Self -ins. Lid. #: Expiration Date: Site Address: City/State/Zip: ach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). lure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 ip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of estigations of the DIA for insurance coverage verification. P Itereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. iature: / stir Date: 4 T i ne #: )fficial use only. Do not write in this area, to be completed by city or town official. ;ity or Town: Permit/License # ssuing Authority (circle one): . Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other '.nrltart Pd -ren". Phnna *- 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 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 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-contractor(s) name(s), address(es) and phone numbers) 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 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 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, Tease do not hesitate to give us a call. he Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-7274900 ext 406 or 1.877-MASSAFE 'Rn -v: 617_797-7749 sM 1- O y C W r ZO��z o < m U 0t -w0 i <.J ca rajm, U - Z �zma j Z J O 1- y Fa- a(�w _ O 0O�F� 5551 LLI"y0 y W_ 0a � J LULL 4 1 I y n?L<L' i Lu 1 1 � m � INTLn N • •. 1 w .' .e Cl) No t _ 9 L). wz 1—Q 'o M o 1 t 00 0. U) w P-4 o m" w AZ ♦7 a V� 0 p> > -!FO o i mL < LUC.�: aQ N J w z cn F- a L')' a w CC W (Y -U) l V Lno O U > w 0 ? ui ' L[1 L ' � #1 11 This certifies that (.1.0 ......... 0 .... .... has permission to perform . plumbing in the buildings of. . IQ_7x.kj . .e ................... at. . o4. 54: ................. North Andover, Mass. Fee Lic. No. ckl.�015. A ................... ... PLUMBING INSPECTOR Check # �' SJ S 1. `rc"V/25 MASSACHUSETTS UNIFORM APPLICATION FOR A TO PERFORM PLUMBING WORK b (PERMIT CITY ✓ MAG DATE / �1��� PERMIT # JOBSITE ADDRESS J/ OWNER'S NAME _ IQZ771- C POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY. TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT NEW ❑ REPLACEMENT: El XNPLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 7 FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN J DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK 77 LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142.. Yes )] No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: 1 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 BOX ONLY: OWNER AGENT ❑ ❑ Signature of Owner or Owner's Agent 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 Chapter 142 of the General Laws. PLUMBER NAME Peter J. Crane SIGNATURE �%��__L' ("�,= LIC # 21805 MP ❑ JP Q CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Crane's Plumbing & Heating ADDRESS: 70 Douglas Street CIN Haverhill STATE IAA ZIP 01830 EMAIL annacrane.ac@verizon.net TEL 978.771.1155 CELL 978.771.1155 FAX `rc"V/25 .t�, The Commonwealth of Massachusetts W,V Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 h ,Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization4ndividual): 4ddress: :�ity/State/Zip; Phone #:. %z cY ,7 / .re you an employer? Check the appropriate box: ❑ I am a employer with 4. ❑ I am a general contractor and I employees (fall and/or part-time).* have hired the sub -contractors 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 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.] i 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 I1.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other y applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. itractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. ,z hn employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site 'rmation. trance Company N cy # or Self -ins. Lid. #: Expiration Date: Site Address: City/State/Zip:. ich a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). are to secure coverage as required trader Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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 :) to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of stigations of the DIA for insurance coverage verification. Itereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Tiicial use only. Do not write in this area, to he completed by city or town official. ity or Town: Permit/License # suing Authority (circle one): Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Other -11"fnrt Parenn• Phnna 44. V, W LL +I Q tLu ypW M i U z F- O�F-p z0Gs U Wiz '-w0 zF CL Z �zmFQ- z J0f-IA fi Q a(1)W +( O20E- O LL�WW W_ �_ ~ J ~ W �QJU N LU (n II S w 2 - i -q n i _ w 2 ". '- co Q Z W 4z U Q `t a I U f roti ZO m Ln U -j L N Q = z Q cn o = Q / v W F- LL, Q w I ! LL m � U J J tt1 Z } co W ' - U J w LU �e Ln Ln t ccs 0- F - I 0 i ' r `a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIU' G (Print or Type) _ t ._NORTH ANDOVER Mass. Date ``lO tui!ding Location ay Permit # c,7L r � , K N • '� Owners Name � • New _ Renovation II RecfacementPans Submitted =j FIY-�rocc (Print or Type) Instailing Company Name HT: NPLy OJEUH Address P, D , 57a,.-/ jV 6 PT MR Check one: Certificate Q Corp. �] Partner. Firm/Co. Business Telephone(71) �-65k- 6'3g2 Name of Licensed -Plumber or Cas Fitter gF �Jp Insurance Coverage: indica-.= :..e ype o: insurance coverage by checking the appropriate box: Liabilii insurance otic 12/ Cz.-er tvice of indemnity .Bond" - - Insurance Waiver: 1, the ur.dersicnec, have been made aware that _the licensee.of this appiication does not have any one of the above three. insurance _coverages._-.- _ Signature of owner/agent of property Owner = -A ent - - - I hereby certify that all of the dctaits and information I have aut:mitted (or entered) in &Love application are true pad accurate to the best of my k.•toWlcdCa and that all plumbin; wort and tnstadatioas . r.Or=ae d urdcr ' r-rr..it .s.-c:d fo: this &prucation will be in eompliastca with ail petlaeat pravisicas of tlse WA&Zacltusetts Slate Cas Cade sad C%&ptcr :43 CC t:r Ccicmi Lara, .-L BV TYnIE' LICENSE • A�� ) 5� � Plummer Title �Gau mer Signature of Li.censec Cit r/Tcur:z- I Master Plumber or Gasfitter journeyman l _�y/9 APPROVED (OFFTC:_ USS ONLY] License Number . m c � us pi 2 � Q UA c F� < < C ?� Q - E.. � t %U _. < tL to H ul N W _ W p. 97 S c W � C -. p _Q — < C C - t7 I-. 2 f 1-• F W W O T U_!- 1 CS F. to Q < cz W } C G W C r � W � < © < � O O O � W U4 � O Q N W sJE—ism—, BASEEeE"iTE I IST FLOOR Z`LD FLOOR j 3Rn FLOOR I I( I 'I -I I I I ( !tt I 1 1I { I I I It-- --1-.. (( -I ---Itt- I --I- -- �--•}t--_ .. ATH FLOOR_L .-.L I I 15TH FLOOR ISTH FLOOR TrK FLOOR aTH FLawt (Print or Type) Instailing Company Name HT: NPLy OJEUH Address P, D , 57a,.-/ jV 6 PT MR Check one: Certificate Q Corp. �] Partner. Firm/Co. Business Telephone(71) �-65k- 6'3g2 Name of Licensed -Plumber or Cas Fitter gF �Jp Insurance Coverage: indica-.= :..e ype o: insurance coverage by checking the appropriate box: Liabilii insurance otic 12/ Cz.-er tvice of indemnity .Bond" - - Insurance Waiver: 1, the ur.dersicnec, have been made aware that _the licensee.of this appiication does not have any one of the above three. insurance _coverages._-.- _ Signature of owner/agent of property Owner = -A ent - - - I hereby certify that all of the dctaits and information I have aut:mitted (or entered) in &Love application are true pad accurate to the best of my k.•toWlcdCa and that all plumbin; wort and tnstadatioas . r.Or=ae d urdcr ' r-rr..it .s.-c:d fo: this &prucation will be in eompliastca with ail petlaeat pravisicas of tlse WA&Zacltusetts Slate Cas Cade sad C%&ptcr :43 CC t:r Ccicmi Lara, .-L BV TYnIE' LICENSE • A�� ) 5� � Plummer Title �Gau mer Signature of Li.censec Cit r/Tcur:z- I Master Plumber or Gasfitter journeyman l _�y/9 APPROVED (OFFTC:_ USS ONLY] License Number . 2844 Date . �/ .� /l ... ... q J* EE * 40RTPI TOWN OF NORTH ANDOVER g p ,,,ao ,s. 4p p� PERMIT FOR GAS INSTALLATION 9 �SSAvE� Mj This certifies that. •••••••••••••••• has permission for gas installation in the buildings of ..f fir.... .... • • .. ��°' % %�� ^- • at .7! . . �,..'....':�.. • .� • • • • • , North Andover, Mass. Ii Fee?!? ..:... Lic. No.%�/� .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOP, PERMIT TO DO GASFITTIN, G (Print or Type) NORTH ANDOVER Mass. Date — 1 uilding Location A2Y,,Z% et S' Y�c/. Permit # y Owners Name �A `? New 7 Renovation Replacement p Plans Submitted p FIXTURES /'t— (Print or Type) C!,.eck one: Certificate Installing Company Name 'Dt ry to Pr = Corp. Address ��vCjPt`�ec-�n,� �� T --j Partner. Noy epees t�� m_Pt 6���14 Business Telephone: (-' q1� Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond Insurzjhce Waiver: I, the undersigned, have been made aware that the licensee of this ap lic tion does not have any one of the above three insurance coverages. Si nature of owner/agent of property Owner i/ Agent I hereby certify that all of the details and information I have tubmitted (or entered) in above application are true and accurate to the best of my knowtcdge and til=t &II plumbing work and installations perforrueA under* Permit iuLed for this application will -be -In complianca with all pertinent pcovisions of the Massachusetts State Gas Code and Chapter 142 of the Genera! Laws, By TYPE LICENSE: lumber Title Gasfitter Signature of Licensed. City/Town- Master Plumber or Gasfitter urneyman o� t'S, APPROVED (OFFICE USE ONLY) License Number vi trs v z rr �, ac #1 C: . o .rn z F us a m cc d v m s c: " o W- W¢� t- a r a z o� = o o E- z rc UA 02 0 H W x w a cc y r ul W ut rn W z U < W X 07 c W O 4 X cc u! F O W Y z rt cs F. x j }- z F. FW. "= a z ClGS w -1 m i W W z Q ya" Q < O O W d. O W P 2 Z Q 0 Y U. Q CL 1-- O SUQ—SS41T. BASEMEXT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5 T K FLOOP. 6TH FLOOR TTK FLOOR STH FLOOR /'t— (Print or Type) C!,.eck one: Certificate Installing Company Name 'Dt ry to Pr = Corp. Address ��vCjPt`�ec-�n,� �� T --j Partner. Noy epees t�� m_Pt 6���14 Business Telephone: (-' q1� Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Q Other type of indemnity Q Bond Insurzjhce Waiver: I, the undersigned, have been made aware that the licensee of this ap lic tion does not have any one of the above three insurance coverages. Si nature of owner/agent of property Owner i/ Agent I hereby certify that all of the details and information I have tubmitted (or entered) in above application are true and accurate to the best of my knowtcdge and til=t &II plumbing work and installations perforrueA under* Permit iuLed for this application will -be -In complianca with all pertinent pcovisions of the Massachusetts State Gas Code and Chapter 142 of the Genera! Laws, By TYPE LICENSE: lumber Title Gasfitter Signature of Licensed. City/Town- Master Plumber or Gasfitter urneyman o� t'S, APPROVED (OFFICE USE ONLY) License Number _.. .` .- . .[�s;�Yti.�' `", ...: _,wt, .]yam••-�M�F.=�^�'�`""''""..'�.'-�. -mss. h .,..,C4:.:�+�. =o g Date. .7— 3.1 .91.e- .. . OF NpRTN TOWN OF NORTH ANDOVER ee p` PERMIT FOR GAS INSTALLATION This certifies that .. D/9 (. ....4. 4 ................ . has permission for gas installation .. i R .Y.e' /Z S .............. . in the buildings of .. Pte'...c C3 ... ..................... . at 3.0...PA P.S,P.* 7, .. , , , . , , N th Andover, Mass. ' Fee. /-?,.7... Lic. No..2. S l:f , .' . 08/05)1%&f 8/QJ/%�`15� PAIDGAS INSPECTOFf WHITE: Applicant Y`. Building Dept. PINK: Treasurer GOLD: File,