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HomeMy WebLinkAboutMiscellaneous - 25 EDMANDS ROAD 4/30/2018Date.91t.(1p. ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........... I.AIL ....... M"76J .......................................... has permission for gas installation ....Pi -e-4, ...+-L .... ..... inthe buildings of .... . ........................................................ .............. at .......... ............................. . North Andover, Mass. Fee..... Lic. No.).,ww6 .......... ..................................................................... GASINSPECTOR Check# L3 ')L G TYPE OR PRINT CLEARLY APPLIANCES Z BOILER MASSACHUSETTS UNIFORM 44LICATION FOR A PERMIT TO PERFORM GAS FITTINGWORK ,� MA DATE EmBun un PERMIT # CITY ��' � ✓� . _.___._- .1 _ JOBSITE ADDRESS, 2 .. ��+�' OWNER'S NAME OWNER ADDRESS . I TELE:::::::7-- FA OCCUPA CY TYPE COMMERCIAL [ EDUCATIONAL ® RESIDENTIAL NEW: RENOVATION: Ej REPLACEMENT: ® PLANS SUBMITTED: YES Q NO FLOORS- BSM 1 1 2 3 1 4 1 5 r 6 7! BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER . INSURANCE COVERAGE have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES a0 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ell OTHER TYPE INDEMNITY 0 BOND Ej 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT bmitted or entered hereby certify that all of the details and information I have sured regarding this application are true and accurate to the best of my knowledge d for this application will be in compliance with all Pertinent provisio of the and that all plumbing work and installations performed under the permit issue Massachusetts State Plumbing Code and Chapter142of the General Laws. ° ,PLUMBER-GASFITTER NAME ! ' /��1 LICENS—E—# — S GNATURE — MGF El JP [3 JGF LPGI ® CORPORATION ©# PARTNERSHIP [j# LLC ®# ANY NAME: -�z __. ADDRESS - STATE PZZZTEL __-EMAIL A CELL 11 a I~i I El z wn CD ii The Commonwealth of Massachusetts Department oflndustrialAccid'ents 1 Congress Sheet, Suite 100 Boston, MA. 02114-2017 www rnass.gov/dia . Compensation Insurance Affidavit: Builders/Contractors/Electricians/Pluxnbers. TO BE FMED WITH THE FERMTTING AUTAORI'I I- Name Addr( City/State/Zip' C)�C1) phone #: A.reyou au employer? Check the approprlate box: 1.uidm, a employer with _employees (fill and/or part-time).* 2_❑ I am a sole proprietor or partnership and have no employees Working for mein any capacity. [No workers' comp. insurance required.] 3.0 lam a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be, hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.Q I am a general contractor and T have hired the sub -contractors listed on the attached sheet. ,. : ,. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corpor@Egn and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and We have rio employees. [No workers' comp. insurance required.] Type of project (required); 7. ❑ New'construdion 8. �] Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repays or additions 12. [] }'lambing repairs or additions 13•. [� Roof repairs 14.r] Other applicant that checks box #7 must also fill out the section below showing their workers' compensation policy information: *Any a P T homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating sue Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entices have rkers' comp. policy number. employees. If the sub -contractors have employees, they must provide their wo I am an employer that is providingworkers' compensation insurance for my employees. ,below is the policy and job site information. i /R.l. — _ A f rn,A .A n. in / d1 ; Date...���..�.P..�`�'..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 1�y: .........1Jj.�.e:.C.c'.k`....................... has permission to perform. ...,. C-?.-,.....,.a'�, ....................................................... wiring in the building of,.,.,, ..., ,. !.�.�.- a -' 9-- ............................................................. J�4� � , North Andover, Mass. at .. .�........ Fee....... ........... Lic. No. ! t.................................................................................... ELECTRICAL INSPECTOR Check # 2681-' i Commonwealth of Massachusetts Official (Use Only ` Permit No. Department of Fire Services Occupancy and Fee Checked s°Y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: q _ 1u - I S City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 2 S IZ Lvv, A,/ Z= N Owner or Tenant `t},,„` J Cc,n, t<., Telephone No. IZ I, - (e`82.- & l g Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building - Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No © (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Completion of the 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 l KVA No. of Luminaires Swimming Pool Above ❑In- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number " "' Tons KW ".."'.""' "'' No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers 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 orEcjuivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (0 Z,qa (When required by municipal policy.) Work to Start: 9 - 11a - I S 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 offic CHECK ONE: INSURANCE W BOND ❑ OTHER ❑ (Specify:) Ycertify, cinder thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:. 4 1 P, A 4- ",C'N111 S LIC. NO.: 41 Sti 2 Licensee: Signature LIC. NO.: A 1S4 2 L' (If applicable nter 11xempt" in the license number lin .) Bus. Tel. No.: (90� �t i2- (4-TIarf o Address: L 6��/U 1 Alt. Tel. No.: (oct- IfI- -Cc4S' *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic 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 ❑ oy er' agent. Owner/Agent PERMIT FEE. $ 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 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 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 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 ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP TION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ZV114.1 Date: 9 - 2_S-- !J'— DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of IndustrialAceldents 1 Congress Street, Suite 100 d oston, MA 02114-2017 B i.awiAl mass gov/dia • Workers' Compensaiionlnsurance Affidavit: Builders/ContxactorslElectricians/Plum ers. TO BE FILED WITH THE PERMITTIlVG AUTHORITX. �, ^ ^ n v, ;„� i Name (Business/Olga'& zat"nadiv"ual): Address: City/State/Zip:- Are you an employer? the appropriate box: Phone #: 1.Q I am a employer with employees (full and/or part time).* 2.Q I am a sole proprietor or partnership and have no employees working foz me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.Q I am a homeowner and will be, hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no eniplbyees. S.QI am a general contractor and T have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. QWe are a corporation and its, officers have exercised their right of oxemption per MGL c. 52 1 4 and'we have no empldyd4' [No workers' comp. insurance required.] Type of project (required); 7. Q NoVdonstxadtion 8. [] Remodeling 9. ❑ Demolition 10 �] Building addition 11.Q Electrical repairs or additions 12. QPlumbing repairs or additions 13•. E1Roof repairs 14. Q Other 1 , § O, •_ *Any applicant that check's box#1_miist also fill out the section below showing their workers' compensation policy information. i homeowners who submii,this, affidavit indicating they aze doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must aft. employees. additional sheet showing the name of the sub contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. Expiration Date:. City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). a criminal violation by a fift up to $1,500-00 Failure to secure coverage as requas ired under MGL n c. 15 inthe form of a STOP WORK ORDER and a fine of up to $250.00 a 25A is and/or one-year imprisonment, day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance coverage verification. X do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct. Date: Signature: in this area, to be completed by city or town Official Official use only. Do not write l. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of 13ealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact 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('1) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub'contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial-Accidenis. 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-A4A.SSA.FE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia GENERATOR APPLICATION DATE: LOCATION: 'Z.'S OWNERS NAME: GENERATOR kw lb NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* PHONE NUMBER: `o3- .6-Z,- qg�L ELECTRICAL RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: TPLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL< Y1jo U. ni COMMONWEALTH OF MASSACHUSETTS Sol r • • �• • BOARD OF ELECTRICIANS ISSUES THE FOLLOWING LICENSE AS A RE.G I STERED MASTER.. ELECT.R I`C`I'ANir . ALPINE ELECTRICAL-'zSERVICE rINC'z R I CHARD- F DE'LVECCH 10 7 DEERF I ELD ST SALEM NH 03079-1373 _.. 15929 A:. 07/31/16: 36133 North Andover MIMAP September 16, 2015 l VON 1114 1— Ci • _ �� - .� ` "i.. .r, '" ,+aL � � ler >� � �,°J �.} � ros �' �;•�"rla ; t �� ���`\ � .x.10-•. 19 • " ``�• . V ', � '!iia`` f «. ,h.,- as � It All ❑ MVPC Be Interstates — 1 — SR NORTH Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map ores produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of Roads , Easements Parcels pf �t�• o , q.{r ? •e �� 3' _ L ^— Lp North Andover. Additional data provided by the Executive Office of Environmental Agalrs/MassGIS. The Information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING at * o•+ ♦ THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION SSACMUSE 1"=34ft ~�° March 30, 2015 NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Claim Number: Policy Number: Company Name: Date of Loss: Insured: Property Location: City, St Zip 033568381 89939400003 Arbella Mutual Insurance Company 2/16/2015 James Crane 25 Edmands Road North Andover, MA 01845 To Whom It May Concern: Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Very truly yours, CC: City/Town Fire Dept, City/Town Health Dept Date ...:................... NORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9 r i I This certifies that ........................................... . has permission for gas installation ........................... . in the buildings of .......................................... at .................................. . North Andover, Mass. Fee......... Lic. No... .......................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING ype or print) Date 14120 -4,3- Z o0b NORTH AIYPOVER, MASSACHUSETTS Building Locations d� ���`%%���5 �� Permit # 3 11 Amount S Ay tv 3AM.0 S Owner's Name New ❑ Renovation ❑ Replacement ® Plans Submitted ❑ (Print or type)', Check one: Certificate Installing Company Name 11,4ZZO/1/�w ��tsay �✓� ❑ Corp. Address /00` xf©l�- S172- ❑ Partner. L.4w17-eAlt-e- 410-. 0/b'41 L Business Telephone /(- g S 1r4—,0,y ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter —7&,14 �f��10��4i✓ • - INSURANCE COVERAGE Check one: I have a'current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy® Other tvpe of indemnity ❑ Bond 11 Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the iviass. General Laws, and that my signature on this permit application waives this requirement. Check one: [DSIanature of Owner or Owner's Agent Owner E3 Agent ( 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 pertbrmed 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. City/Town A-PPROVED (oFru- USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber A L.,� g ❑ Gas Fitter :cense ( um6er ❑ ivlaster r -q Journeyman r (Print or type)', Check one: Certificate Installing Company Name 11,4ZZO/1/�w ��tsay �✓� ❑ Corp. Address /00` xf©l�- S172- ❑ Partner. L.4w17-eAlt-e- 410-. 0/b'41 L Business Telephone /(- g S 1r4—,0,y ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter —7&,14 �f��10��4i✓ • - INSURANCE COVERAGE Check one: I have a'current liability Insurance policy or it's substantial equivalent. Yes No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy® Other tvpe of indemnity ❑ Bond 11 Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the iviass. General Laws, and that my signature on this permit application waives this requirement. Check one: [DSIanature of Owner or Owner's Agent Owner E3 Agent ( 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 pertbrmed 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. City/Town A-PPROVED (oFru- USE ONLY) Signature of Licensed Plumber Or Gas Fitter ® Plumber A L.,� g ❑ Gas Fitter :cense ( um6er ❑ ivlaster r -q Journeyman Date. N2 TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING ,SSACMUs� This certifies that .... .................... ........ ... has permission to perform .... .`...: f :::=r .......... plumbing.in,the buildings of ..... ' .. '..................... at .. ::. .................... North Andover, Mass. F . Fee.. « ...... Lic. No . ` ..` .... ..... `. ........... PLUMBING INSPECTOR Check # `= WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATIONZPERMITDO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTSBuilding Location S Q� /�/� S �� OwnersName J l S C#4 G c! 7 Amount Type of Occupancy New M Renovation 1:1 Replacement El Plans Submitted Yes n No (Print or type) Check one: Installing Company Name //4 Corp. Addressd �D X S�OZ ❑ Partner. /-AAle ec—le- M4. 0/9V7— '— 1!57 /9V7- 95 0 Lj Firm/Co. Name of Licensed Plumber. %6u1 /7%//OAC fid Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy W Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information 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 Stag Plumbing Code and Chapter 142 of the General Laws. By:igna ot Licensedum er Type of Plumbing License Title I [/933 City/Town License Number Master ❑ Journeyman ITM APPROVED (OFFICE USE ONLY • (Print or type) Check one: Installing Company Name //4 Corp. Addressd �D X S�OZ ❑ Partner. /-AAle ec—le- M4. 0/9V7— '— 1!57 /9V7- 95 0 Lj Firm/Co. Name of Licensed Plumber. %6u1 /7%//OAC fid Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy W Other type of indemnity ❑ Bond ❑ Certificate Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information 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 Stag Plumbing Code and Chapter 142 of the General Laws. By:igna ot Licensedum er Type of Plumbing License Title I [/933 City/Town License Number Master ❑ Journeyman ITM APPROVED (OFFICE USE ONLY J Date....F................. r. - - o � TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........................................... has permission for gas installation .................. in the buildings of ................................ at ...................................... North Andover, Mass. . Fee.' .......... Lic. No........... ..... GAS INSPECTOR Check e MASSACHUSE I'TS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING A], Mass. Date Z&,�L 26n&___ Permit 5�759 IN f Building Location -Owners Name/////, • • - New ❑ Gr-- SUB-13SMT. BASEMENT .��� IST FLOOR 2ND 3R3RDFLOOR �-- 4TH FLOOR STHFLOOR ��— 6T6THFLOOR �.�_ 7THFLOOR _ STH FLOOR Renovation ❑ Replai emen . ' Plans Submitted: Yes❑ No ❑ Installing Company Name 'Ar; -(Z T A . ` AM MA T A X20 Check one: Certificate Address 30 Cb A C H 1h A ,y 4 -KI. O Corporation M E T H U E tJ r11 rj D( k g ❑ Partnership Business Telephone 6 91 - 5 9- f 2-,Rrm/Co. Name of Licensed Plumber or Gas Fitter --R o jjE P T A - S A m m f4 ! A k0r > -- INSURANCE COVERAGE: I have a current I' bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes lNo ❑ If you have checked ves. please Indicate the type coverage by checking the appropriate box A liability insurance policy dQ ' 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: Owner[] Agent ❑ Signature of Owner or Owner's 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 the pe i ued for this application be in compliance with ail ,pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. By T of Ucense: G� Plumber n ure of cen u or fitter Title tter or License Numberya3 ) City/Town Journeyman IC � y y W y yL Z Q y y H = F - W W O V' C7 J y F i} Z 2 0 �. W z O W< < o O 10 Z ►- W <= �- ; C y O VW N Z < CC O W < W us � W C O Z. < Q<< -C) o O W O W M- I ac z 0 �% x U. O; G J C� > G O F- O Installing Company Name 'Ar; -(Z T A . ` AM MA T A X20 Check one: Certificate Address 30 Cb A C H 1h A ,y 4 -KI. O Corporation M E T H U E tJ r11 rj D( k g ❑ Partnership Business Telephone 6 91 - 5 9- f 2-,Rrm/Co. Name of Licensed Plumber or Gas Fitter --R o jjE P T A - S A m m f4 ! A k0r > -- INSURANCE COVERAGE: I have a current I' bility insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes lNo ❑ If you have checked ves. please Indicate the type coverage by checking the appropriate box A liability insurance policy dQ ' 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: Owner[] Agent ❑ Signature of Owner or Owner's 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 the pe i ued for this application be in compliance with ail ,pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. By T of Ucense: G� Plumber n ure of cen u or fitter Title tter or License Numberya3 ) City/Town Journeyman IC • o r v W. -- CL N — - _z N N W Q d ' O Q d v I1- N } J � = � o - • O W O W � F } � z � ui V ,E ccW O O 116 O W z ~ O • O z i C j z Q o _ W IL y, O d m ., S6 3 O oul m a - W m V IL O O } J Oid W m O z w NJ W a o 1L z a J NI r W V W Y N z O_ tj W N 2 J a 1