HomeMy WebLinkAboutMiscellaneous - 245 BRIDLE PATH 4/30/2018 (6)N
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(ASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FPITIN
)r print) Date IJ 19
I'4%JK I H ANDOVER, MASSACHUSETTS
Building Locations d% -1 , 5 >i< 1V* -LA- "4-x \-1 \ h
�-\P-Nlse- Gan q Owner's Name
New ® Renovation ❑ Replacement 111:1Submitted ❑
Permit # -.9 doe, 4/
Amount $ 442j;
(Print or
Address
ness
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
, ❑ Corp.
❑ Partner
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ED No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy J-7-1 Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of I
Plumber
Gas Fitter
Master
Journeyman
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SUB-BASEiM ENT
BASEMENT
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1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7T 11. FLOOR
Ell
d
RT I1. FLOOR
(Print or
Address
ness
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
, ❑ Corp.
❑ Partner
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ED No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy J-7-1 Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of I
Plumber
Gas Fitter
Master
Journeyman
2 864 /2
Date. .... " ..........
ri
TOWN OF NORTH ANDOVER
3 " PERMIT FOR GAS INSTALLATION
� 9
+ + Q
s
SSACH
USEt yy��
CU
This certifies that . �.......... ? ....... " .................... .
r / ;i r
has permission for gas installation ..! ....¢ ... ...
t � M
in the buildings of ....... ... ... . ............ .
..
atte. ............ r. `?,.L....... North Andover, As.
.r
Fee! ? .... Lic. No �!.G . � . .
�.
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATIO
(Print or Type)
G
FOR PERMIT TO DO GASFITTING 767L,!�"
� %Y-%1 pu'(','e Mass. Date S %>` 19 "�
=I
Building Location c�- F/Z /c71e �/L�7 A/ Owner's Name L'M h��a4 SS CJ
Telephone Type of Occupancy Ze-, /Ip n
New ( Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No p
Installing Company Name zh e,8 4 V 0 Sf -7/2 C, J Check one: Certificate
Address o� CEO i�✓e51 �AR ,412 R I v e Sa p Sop Corporation C .
we5f A*AoaeA%i,a Q/i S/ ❑ Partnership
Business Telephone 30 8 S 7/ % / :nO , .1 O Firm/Co.
Name of Licensed Plumber or Gas Fitter k//1-1. I7ti /rNh C"ASPh
INSURANCE COVERAGE:
I have a curren lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
F014 Yes M No O
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy llr7 Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent [I
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General taws.
BY T of license: 2.� -
Plumber Signature of licensed Plumber or Gas Fitter
Title asfitter 3 ,7 ,�
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONL
■ENNEN
nUMINE■
IMMINiMIMMEN
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so
NONE
on
SEEN
opt 0
. • •
���������������������■
son'
Installing Company Name zh e,8 4 V 0 Sf -7/2 C, J Check one: Certificate
Address o� CEO i�✓e51 �AR ,412 R I v e Sa p Sop Corporation C .
we5f A*AoaeA%i,a Q/i S/ ❑ Partnership
Business Telephone 30 8 S 7/ % / :nO , .1 O Firm/Co.
Name of Licensed Plumber or Gas Fitter k//1-1. I7ti /rNh C"ASPh
INSURANCE COVERAGE:
I have a curren lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
F014 Yes M No O
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy llr7 Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner❑ Agent [I
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General taws.
BY T of license: 2.� -
Plumber Signature of licensed Plumber or Gas Fitter
Title asfitter 3 ,7 ,�
Master License Number
City/Town Journeyman
APPROVED (OFFICE USE ONL
286/
Date ........ ...� .. .
HORTM
TOWN OF NORTH ANDOVER
pf .ao ,e11•Q
p�
D
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PERMIT FOR GAS INSTALLATION
/ �%
This certifies that ......... ,�� ....................... .
has permission for gas installation .........
in the buildings of ....:..,.... . `-J ��J`.:'�.. • .. .
��, - t
at .. i �:.!�;..�.��!��:-:�' ..... .. �!.... , North Andover, 1Vfiss.
FeelZ.`.:.... Lic. No....... 1... ..........................
GAS INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... lir .......... ............� .......................
. ........ .
has permission to perform . . ................................................
wiring in the building of ..................................................
,at . ...... .-NJ orth Andover, Mass.
Fee-Z/J-) Lic. No: ..........
EE
Check # gg7,
8156
NORT"
z°;4•"°;° a"o Zoning Bylaw Review Form
y1 p Town Of North Andover
Building Department
gan�rea nPP��'l'
�ITSA�Mt15Et 1600 Osgood Street, Building 20, Suite 2-32
North Andover, MA. 01845
Phone 978-688-9545
Fax 978-688-9542
Street:
245 Bridle Path
Ma /Lot:
64/74
Applicant:
Denise Grasso
Request:
Detached 3 -stall garage
Date:
6-21-06
Please be advised that after review of your Application and Plans that your Application is
DENIED for the following Zoning Bylaw reasons:
Zonina District: R-1
Remedy for the above is checked below.
Item # Special Permits Planning Board Item #
Item
Notes
Setback Variance
Item
Notes
A
Lot Area
Common Driveway Special Permit
F
Frontage
Variance for Watershed Buffer
1
Lot area Insufficient
Independent Elderly Housing Special Permit
1
Frontage Insufficient
Earth Removal Special Permit ZBA
2
Lot Area Preexisting
X
2
Frontage Complies
Other
3
j Lot Area Complies
3
Preexisting frontage
X
4
Insufficient Information
4
Insufficient Information
B
Use
5
No access over Frontage
1
Allowed
G
Contiguous Building Area
2
Not Allowed
1
Insufficient Area
3
Use Preexisting
X
2
Complies
4
Special Permit Required
3
Preexisting CBA
X
5
Insufficient Information
4
Insufficient Information
C
Setback
H
Building Height
1
All setbacks comply
1
Height Exceeds Maximum
2
Front Insufficient
2
Complies
X
3
Left Side Insufficient
3
Preexisting Height
4
Right Side Insufficient
4
Insufficient Information
5
Rear Insufficient
X **
I
Building Coverage
6
Preexisting setback(s)
1
Coverage exceeds maximum
7
Insufficient Information
2
Coverage Complies
D
Watershed
3
Coverage Preexisting
X
1
Not in Watershed
4
Insufficient Information
2
In Watershed
X
j
Sign
3
Lot prior to 10/24/94
1
Sign not allowed
4
Zone to be Determined
2
Sign Complies
5
Insufficient Information
3
Insufficient Information
E
Historic District
K
Parking
1
j In District review required
1
More Parking Required
2
Not in district
X
2
Parking Complies
X
3
Insufficient Information
Remedy for the above is checked below.
Item # Special Permits Planning Board Item #
Variance
Site Plan Review Special Permit
Setback Variance
Access other than Frontage Special Permit
Parking Variance
Frontage Exception Lot Special Permit
Lot Area Variance
Common Driveway Special Permit
Height Variance
Congregate Housing Special Permit X
Variance for Watershed Buffer
Continuing Care Retirement Special Permit
Special Permits Zoning Board
Independent Elderly Housing Special Permit
Special Permit Non -Conforming Use ZBA
Lar a Estate Condo Special Permit
Earth Removal Special Permit ZBA
Planned Development District Special Permit
Special Permit Use not Listed but Similar
Planned Residential Special Permit
Special Permit for Sign
R-6 Density Special Permit
Other
X Watershed Special Permit
Supply Additional Information
The above review and attached explanation of such is based on the plans and information submitted. No definitive
review and or advice shall be based on verbal explanations by the applicant nor shall such verbal explanations by the
applicant serve to provide definitive answers to the above reasons for DENIAL. Any inaccuracies, misleading
information, or other subsequent changes to the information submitted by the applicant shall be grounds for this review to
be voided at the discretion of the Building Department. The attached document titled "Plan Review Narrative" shall be
attached hereto and incorporated herein by reference. The building department will retain all plans and documentation
for the above file. You must file a new building permit application form and begin the permitting process.
t
Building�P em
par r` a }r Official Signature Application Received ApOicatiofi Denied
Denial Sent: If Faxed Phone Number/Date:
Plan Review Narrative
The following narrative is provided to further explain the reasons for denial for the building permit
for the property indicated on the reverse side:
Review Reasons for Denial & Bylaw Reference
Form Item
Reference
C/5 A Variance from the Zoning Board of Appeals is required for new permanent
structures in the Non -Disturbance Buffer Zone of the Watershed Protection
District per 4.136.3.c.ii.3 of the Zoning Bylaw.
D/2 A Watershed Special Permit through the Planning Board may be required from
Section 4.136 of the Zoning Bylaw as the Special Permit Granting Board for
the Watershed Protection District.
Referred To:
Fire
Health
Police
X Zoning Board
Conservation
Department of Public Works
X Planning
Historical Commission
Other
BUILDING DEPT
ZoningBylawDenia12000
9 Tn� "•••.1.v.rvvcalin or massachusetts
Department of Fire services
BOARD OF FIRE PREVENTION REGULATIONS
--------------
OfficialUse Only
Permit No.
Occupancy and Fee Checked. l'
Lev. 1/07) (leave blank,
APPLICATION FOR PERMIT TO PERFORM ELECTRIC,
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR
(PLEASE PRINT W INK OR TYPE ALL WORMATION) Date: -20
City or Town of. NORTH ANDOVER
By this application the undersigned gives notice res
of hisror her intention to erform the
nelle tical yvpector I jesci
Location (Street & Number)
r
Owner or Tenant . �d K h � S l
0 /Telephone No.
Owner's Address � ayo (�
below.
' /
Is this permit in conjunction with a building permit? Yes '
Purpose of Building No' -
(Check Appropriate Boz)
Utility Authorization No.
Ezisiing Service Amps / Volts '
Overhead ❑ Undgrd No. of Meters
New Service s
AmP Volts Overhead ❑ Unda d ❑ No. of Meters
Number of Feeders and Am am
RK
F tY
Location and Nature of Proposed Electrical Work: i r
� fCt
Completion o the ollou i table maybe waived by the 1 ector of Wires.
No.�ofRece"�sseduminair�,�3No. of Cell. -Sus No. of
p. (Paddle) Fans Total
1o. of Laminaire Outlets
To. of Luminaires
lo. of Receptacle Outlets
fo. of Switches
'o. of Ranges
o, of Waste Disposers
o. of Dishwashers
No. of Dryers
No. of Water
Heaters
KW
No. Hydromassage Bathtubs
ti -
OTHER:
q
INo. of Hot Tubs
!Swimming Pool .A ve
d.
No. of Oil Bure
n- rs --_
No. of Gas Burners
No. of Air ConcL °
Pace/Area Heating KW
:eating Appliances KW
o. of No. of
Sins Ballasts.
o. of Motors Total HP
LL auerurmers "TA
Generators KVA
o• o metgency rwo
Batte Units
FIRE
ALA RM, No, of Zones
o. of etection and
Initis ' Devices
No. of Alerting Devices
o. of Self: Contained
t
Aler tin Devices
unicpalonnectt ❑ Other
ysteevices or E uivalent
ng:evices or E uivalent
unications
No. of Devices or Eaniva ent
Estimated Value of Electrical Work: Attach additional detail if desired, -or as required by the Inspector of Wires.
Work to Start (When required by municipal policy.)
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 ❑ 0
❑ (Specify:)
I certify, under the pains and penalties o er, jury, that the information on this application is true and complete.
FIRM NAME:
Licensee: S. LIC. NO.: R ��
a lcabl - enter "ezemp t " in the license nu ber line.) mature
�fPPi— LIC. NO. Z Qj % %a
Address: , pt 0 3, 7 Bus. Tel. No.:
*Per M.G.L c 147, s 57-61, security work requires DAlt Tel. No.:
ePartnent of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAVER: I am aware that the Licensee does not have the liability ins
required by law. By my signature below, I hereby waive this requirement urance coverage normally
Owner/Agent I am the (check one) owner ED owner's agent
Signature Telephone No. PERMIT FEE: $ `
;�
a
t
The Common wealth ofMassachuse&
Department of Industrial Accidents
office of Invesddgations
600 Washington Street
Boston, MA 02111,
wWw.m s gov/dda
Workers' Compeasaiioa inshtranee Affidavit Builders/Contractors/Eiectricians/Pfambers
Atiniicant Information
. r��Se 1'rini Lf:Qib
A1ame(BnsincsslOrga�airaiioniIndivid�tafl'+ �(j ��f � CC19��C �D� ,�
r l
Address: Jio
City/,State/Zip: a �fl� ,/17 Q 3a ? Phone # . 7 n
A
re you an employer? Check the approPnate-boz:
I. ❑ I
am a employer with
4. ❑ 1 am a Meral contractor and I.
�fnployees (full and/or part-time).* .
U.
2. ' I am: asole proprietor or
have hired the suh-carni =rs
listed
partner-
ship and have no employees
on the attached sheet I
These sub -contractors have
working for me in any capacity..
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its .
required.]
3. D I am a homeowner doing
officots have exercised their
all work
right of exemption per MGL
myself,. [No -workers' comp.
Q. 152, § I (4),'and we have no
insurance required.) t
employees, [No workers'
.
comp insurrsnce teed.
Type -of project (►•eq'aired):
6. New construction
7. ❑ Remodeling
8. Q Demolition`
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.[] Plumbing repairs or additions
12.E Roof repairs
requ I3.M.Other
"Any applicant tat hchecks ba # 1 moat also f[r 1 out the section below
1 Homeowners who submit this afilaavit indicating fhey aM doing ,,
a.ing their workers' oompensatioii poiuy mformahon
shshowing
than hire outside connectins must
1__Gob ctors that check this box mustatnsohed an additioasl sheet rho submit a new affidavit indickd arch
►r'hrg the Morn_ of die sub.�s and their work=, cotua, poli
1 ant an employer that.is .ro �y in%tmation.
�+ f rid&tg:workenr compensadors insurance
for for t' mnployem Below is -Me policy and joh site
Insurance Company
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the .workers' coot City/StBte/Zip:
« pensation policy decEaratian page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 352 can lead to the imposition of criminal
. offine up m $1,500a and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDERand
of i
In a to tionsS250.0 a day against the violator- Be advised that a e of this statement may be forwarded a nue
Investigations of the DIA for insurance coverage verification. y . d td the Office of
I do hereby cerci under the pains acrd pen ofPerjury J*ar the ormadon in f p ro
vcded above is tare and correct
Si rture, Date: S 2 -
Phan Phon
Offwi& use only. Do not'.write in lids area, to be coarpletedtown or o
fficiaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health ? Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
b. Other
�� Contact Persia:
Phone #
Information and Instructions
Massachusetts General Laws chapter l 52 requires all emp 3 dyers 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, assodiation, corporation or other legal entity, or any two ormore
ofthe'foregoing engaged in a joint errterprise, and including the legal representafives of a deceased employer, or the
receiver ortrustee•of an individual, partnership, association, or other legal entity, employing employees. 'However the
owneir•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 ma ritermce, construction or repair woirk an such dwellinghouse
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 at- local iiedusing 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 evidencx.of compliance with the insamance coverage required."
Additionally, MGL chapter 152, WC(7) states "Neither the commonwealfh`nor any of its political subdivisions shall
enter into any contract for the pm*rmanee of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s� addresses) arsd phone number(s) along with their c errificate(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
employe, a policy is required. Be advised that this afrtiavit.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 f
Industrial Accidents. Should you have any questions regarding the law or if you .= requi�ad to obtain a workers',
compensation policy, pleasr call the Department at the nurnber.listed below. Self-insured companies shouitl enterthi=.
self-insumnce•.lieense. aumber on fie appropriate lin-.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hes 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/Iicanse 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 "Jab Site Address" the applicant should write "all locations in (city or
town).." A copy ofibe 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 f dorm 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 of permit to bum leaves etc.) said person, is NOT required to complete this affidavit.
The Office of Investigations would Re 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 Stieat
Basion, MA 02111
` eL # 617-72-74900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax;9 617-727-7744
www.mass.gov/dia
0
Date.. .... ...... n 0.. s f
NORTH ZDOVER ti0
° TOWN OF NORTH
f A
;- PERMIT FOR GAS INSTALLATION
4
This certifies that . `r�-�-.... . U-.!p.n. �!� - ......
has permission for gas, installation_.-r�Z- :.. f�.?U......
in the buildings of ..: °-.,........................
at c,? ... ... ... ..... ,North Andover, Mass.
Fee. ?�Lic. .: .........
GAS INSP
Check # In /
6413
MASSACHUSETTS UNIFORM APPUCATON FOR PERNUr TO DO GAS FITTING
(Type or print) Date-�—�
NORTH ANDOVER, MASSACHUSETTS
Building Locations Permit # (Ol3
Amount $ 3a
Owner's Name jo 6 2 pws�
New ® Renovation ❑ Replacement ❑ Plans Submitted ❑ -6A4? mss, e—
G
SU B-BASEM ENT
BASEMENT
1ST.
FLOOR
2ND.
3RD.
4TH.
FLOOR
FLOOR
FLOOR
5TH.
FLOOR
6TH.
FLOOR
7TH.
8TH.
FLOOR
FLOOR
(Print or type)
Name
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
ElFirm/Co.
A Name of Licensed Plumber or Gas Fitter _ ;y
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes ® No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ® Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St�2as,gode aid Chapter 142 of the General Laws.
By:
Title
IAPPROED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 3 , c� !�
Gas Fitter License Number
® Master
❑ Journeyman
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Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
ElFirm/Co.
A Name of Licensed Plumber or Gas Fitter _ ;y
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes ® No❑
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy ® Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ 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 Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts St�2as,gode aid Chapter 142 of the General Laws.
By:
Title
IAPPROED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber 3 , c� !�
Gas Fitter License Number
® Master
❑ Journeyman