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HomeMy WebLinkAboutMiscellaneous - 25 HAROLD STREET 4/30/2018------' ---�_ . .1 . .-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i has permission for gas installation .. ?.4 -. , e in the buildings of ... `J ."(.AA .. `-' � ................ . . at .....s �.. ...$ . ... t� .... , . ,North Andover, Mass. Fee O G`) .. Lic. No... 3 `� .b ..... . GASINSPECTO Check #p 8395 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATELaJID., j PERMIT #� _._,.. JOBSITE ADDRESS 5 OWNER'S NAME GOWNER ADDRESS TEL, p" a FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ® RESIDENTIAL CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO APPLIANCES 7 FLOORS BSM 1 1 2 3 4 5 6 7 8 9 1 10 11 12 1 13 1 14 BOILER _. _._. Wi n. --T__ i _....-.._� BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER—` DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR' GRILLE._...._-..; INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN E- ; .; ---j POOL HEATER" ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ I IF YOU 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true a a to t e f my kn Y ledge and that all plumbing work and installations performed under the permit issued for this application will be in co c t Pe n e Massachusetts State Plumbing Code and Chapter 142 of the General Laws, PLUMBER-GASFITTER NAME I STEVEN J. ADDARIO JR LICENSE # 13106 S1GNATURE MP ❑ MGF ® JP ® JGF ® LPGI ® CORPORATION Ej# 13106 PARTNERSHIP❑#D LLCF-1# COMPANY NAME: ADDARIO'S INC. ADDRESS 120 COOPER STREET CITY LYNN STATE MA ZIPTEL 339.440.8100 FAX 1339.883.3059 CELLI 781.760.5367 EMAIL dispatch@addarios.com i� W E� zz z 0 U .a w IN � ` a Z❑ z o N D d r W ►7 ~ W O w O z F" a 4LU W ~ to w U) a W W f� O W Q W N ra a O Q a Q � U rr x J E.. CL a.�s a � w 2 W H LL W H 0 z 0 H U W a z x a 0 a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations WJ 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): /—S 2Ne Address: C City/State/Zip:_ 1 AX) M4 0 190rj Phone #: 3,3`l. q 0 Are y an employer? Check the appropriate box: Type of project (required): 1. I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. + 7• ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL I I. -Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] employees. [No workers' 13.❑ Other comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workcrs' compensation policy information. t 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. E - I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: L.- f ,Q /� pry /n U y"Zt & Z G tot 6 U) Policy # or Self -ins. Lic. #: Expiration Date: %'2 — o2g • C% Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. I52 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Sip -nature: Date: Phone #: Oficial use only. Do not write in this area, to be completed by city or town off ial 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 #: rf COMMONWEALTH OF MASSACHUSETTS PLUN-LERS AND GASFITTERS LiCENSUE. AS A MASTER PLUMBER PS4tIt - I#it AE+Cuf � it E-tj5; TO STEVEN J ;',DDAR 10 JR 331 MAIN f T BOXFORD 4A 01921-2225 13106 05/O.i/14 164821 :N2 9624 DateA01 i:j 1?-. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that has permission to perform . .. �. . � ......... . plumbing in the buildings of .�0 (^ .. '�'�. 1!t c� ........... . �t a«. ��' ' .......... , North Andover, Mass. Fee2A`P .. Lic. No. \�j�C� �.. ..... t�%4l� PLUMBING INSPECTOR Check # + ' • WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 4 'r " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK – 6 CITY MA DATE I a PERMIT # JOBSITE ADDR SSa 5 OWNER'S NAME - OWNER ADDRESS TELI, 3%07 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: ® RENOVATION: El REPLACEMENT PLANS SUBMITTED: YES ® NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER L 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 [j OTHER TYPE OF INDEMNITY E] BOND Q 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: OWNERE] AGENT E] SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a to to th e_ of my kno edge and that all plumbing work and installations performed under the permit issued for this application will be in co I Pe ' vision o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Af,4 PLUMBER'S NAME STEVEN J. ADDARIO JR. LICENSE # 13106 NATURE MPE] JPEl CORPORATION 3102 PARTNERSHIPQ# LLC ®# COMPANY NAME I ADDARIO'S INC ADDRESS 1 20 COOPER STREET CITY LYNN —� STATE MA ZIP01905 TEL [339-440-81 00 FAX 339.883.3059 CELL 1781.760.5367 1 EMAIL dis atch@addarios.com w F O z z w a w Q oEl Z Z }E o w p W O w a ac z uLU w w C a W a C� w CL Ix 3 N O o a a 2) w a � U J IL IL r� a Li.i = W H LL. W F O z z 0 F U W 96 z z as a a x L7 D O a , • �.\ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Worke ' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers licant formation 1P14PaeP Print T n..;l.l. Name Address: I's city/ State/Ze p: �.-y/1/j) �f %� C� / Q� `� Phone #: 339. L1 tf o . ,;-') ti -6 Are y an 1. Iama 2.❑ Iam' asol ship and 1 working [No work required.] 3. ❑ I am a hot myself. [P insurance *Any applicant that t Homeowners who +Contractors that ch i am an emp information. Insurance Cc Policy # or Self -i Job Site Address: Attach a copy of Failure to secure c fine up to $1,500.( of up to $250.00 a Investigations of tl I do hereby certify Boyer? Check the appropriate box: loyer with 4. ❑ I am a general contractor and I (full and/or part-time).* have hired the sub -contractors proprietor or partner- listed on the attached sheet. t ve no employees These sub -contractors have T me in any capacity. workers' comp. insurance. S' comp. insurance 5. ❑ We are a corporation and its officers have exercised their ,owner doing all work right of exemption per MGL workers' comp, C. 152, § 1(4), and we have no ,quired.] T employees. [No workers' comp. insurance required.] cks box #1 must also fill out the section below showina their k ' Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I.53 -Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other this affidavit indicating they are doing all work and then hire ors utside compensation actors mu'stsubmit a new affidavit indicating such. box must attached an additional sheet showing the name of the sub -contractors and their workers' Como. nolirvinfnn .t;.. !at is providing workers' compensation insurance for my employees. Below is the policy and job site Name: / / L7 :_ 7-',1 , , r% Q A . 1 n Lic. #: / -3/ �gfQ S �'.. p / / Expiration Date: /-;2,- oZ9 -- h2, City/State/Zip: e workers' compensation policy declarationa e p g (showing the policy number and expiratiof(date). ,erage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine ty against the violator. Be advised that a copy of this statement may be forwarded to the Office of DIA for insurance coverage verification. 1,,rrnepat d pe of pe ' that the information provided above llis to and correct Date. / l flJ / / �oZ� 'hone #:------------ Oficial use onli Do not write in this area, to be completed by city or town official I I City or Town: 1 Permit/License # Issuing Authori(circle one): 1. Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person:1 Phone #: I� W etp/noS'ssetu'nVAMj 0-9Z-5 Pastnall 6t,LL-LZL-L 19 # Xe3 1 33HSS` W-LL8- 1.10 90b M 006V-LZL-L 19 # '101 i I I I Z0 vWuolsog laaalS uolSU'gseM 009 saoueapsanuI;o aaulo sluappaV jeulsnpui jo luauzlaeda(l sllasnpessew jo glteamu0URU03 aq L :aagwnu xr3 puu ouogdalal `ssaappu s,lu wlagdaQ oqs -Ileo g sn aAlB 01 algltsaq lou op asuald `suotlsanb ,Cut, angq no,c Plnogs put, uotlgaad000 ano,C lo3 aournpu ut no,( Imp of axtl pinonn suotlleBIlsanul, o Dom au •ltnlePg3g snp alaldwoo of pannbaa jLptq sl uosaad pius (•ola sant,al uanq of ltuuad ao asuaorl 0op r •a -t) aanluan 11313aaww03 ao ssaursnq ,Cole o1 palt,laa lou 1luuad ao asuaorl g Bututgl(10 sl uazlllo ao aaunmo awoti a aaatiM •aga,C rot, t g nnau sasuaor ao sltuuad aanln3 a03 aig uo sl 1ingptJg P11rn g lggl3oo d sle luuorlddu gora Ino Pallg aq Ism 1. P33 d .l aqI of paptnoad aq ,Cruz umol .co ,t110 aqi ,Cq pailzuur ao padurels f,Illeto33o uaaq sgg 112g1;tngpg3le agl jo ,Cloo d «(umol Jo A!o) u1 suopgool llr„ altann pinogs luuotlddr atg ,,ssaappd altS qo f„ .spun pug (,C.russaoau 3t) uotl uuo�ut �otlod luauno Ouprolput ItnuptWV aro ltwgns ,Cluo paau `araC uan12 ;:ug ul st orlgoriddr asuaotl/Ituu ad aldtlmw atgns ism wul luuotlddu ule `uotntppu ul •aagwnu aouaaalaa r sle pasn aq Ilton golgnn aagwnu asuaorl/lluuad ag1 u1 jig ohms aq asuald •lurotlddu agI Butpaugaa no,c lolelum of suq suotlg9tlsanu1 JO a3WO age Juana ayui Ino lira of no,C ao3 nuprju ag13o wouoq atp lie oot,ds le papinoad sug luampsclaQ aqs •,C1Q1ga1 palutad puu alaldwoo s1 linupgJu alp I1211 ans oq asrald slal3W0 nno;Lao,Ul3 awl olt,udoaddu agl uo iagwnu asuaoti ameinsut alas 11041 aalua pinogs saiurdwoo paanstu 31aS •nnolaq palsti aagwnu alp 112 luautlardoCl aqJ lluo ascald `,C3110 uotlgsuadwoo ,s.taNioM u utielgo of paambaa amno,C31 ao mel agI gu1Pat,8aa suotlsonb ,cru anleq no,C pinogS •s1u3Pj33d Imnsnpul 30 luauzlagdao agI;on `palsanbaa Sutaq st asuao11 to ltuuad agI ao3 uo.1go11ddie aqJ 112121 unnol ao ,Cleo atiI o1 pauanlaa aq pinogs itnrptwg aU •;ingpWe aq; aisp pus u%'s o; awns aq osld 'aSraanoo aourmsu13o uotlruuguo ao3 sluaptooy lutalsnpul 3o luau ndaQ aql of ponluzgns aq ,Cgw Itngp33r stgl 11211 Pasrnpg ag paatnbaa st Xotl g `saa,Coldwa anleq scop d -l -I ao D-1-1 ug 3l •oougmsut uolllesuodwoo �sialiom ,cuuo of paambaa lou aag `saa'� dao saagwaw oql ut,gl aaglo saa,Coldwa ou gIIM (d'I'I) sdlgslauut,d /14tltglet'I pollwi-i .to (3.1-I) saiugdwo:) Arltglet'I Pali�it'I •aougmsul 3o (s)alleogtlaao atagl glrnn Suo1r (s)aagwnu auogd pule (sa)ssaapple `(spumu (s)aolouquoo-qns AI dns `,Ctussaoau 3t `pug uoilrnits ano,C of � Addie lt,g1 saxoq agI Suploago Xq `Alalaldwoo ltnrpg3g uoilrsuadwoo �siaVom aq I Ino jig aseald s;usallddV «•,cllaoging Suilogaluoo aql of paluasaad uaaq angq aaldugo stgl s;uawaambaa aouransut aql tiltnn oouuildwoo3o aouaptna alquld000r itlun )lrom otlgnd jo aouguuo3aad ag1 aoj lo12aluo; ,Cur olut aalua llugs suotslnrpgns it,otlllod sl! jo ,Cut, jou gllleanmuowuroo aql lotpta11„ salrls (L)DSZ§ `ZSI aaldrgo 'lJl� `Alluuotl!PPV «•paalnba t aSsaanoa amsansul aq; gjlm aauslldmoa 3o aauapina alga;daaas pampo.zd ;ou ssq',ogmjusagdds Sus aoj tr;lgansuomwo3 aq; ul silutpllnq pnilsucra olio mmsnq s ale.Wo o; ;!Woad .w asu*� s jo lsmaua z ao aausnssl aq; plogq;ln+ llsgs ,faua2s 2ulsua3ll Isaol JO a;s;s Raana„ 11211 salols oslg (9)�SZ§ `ZsI* laJdggo 'low « aa,Coldwa ule oq of pawaap oq luatuXoldwa tions 3o asnleoaq lou llugs olaaagl lurualmddr Ompltnq ao sptmoa21 alp uo ao asnoq Sutll2mp Bons uo �iaom .rtrdo.t io uotlon.usuoo `aout,ualutleuz op of suosaad s,Coldwa oigm aagloug joi asnotiftillamp agl3o lurdn000 atil ao `ma ratil saptsaa oqm put, sluawlaudz aaagl uegi aaow lou 2utn12l,asnog OuilC amp u 3o aau ag1 aanannol-1 •saa,Coldwa 3ut,coldwa `rtltlua lroal ta1Jo ao uoilt,roossu `drgsaaulaled `lrnptAtpui uu3o as snal ao aanlaoaa agI ao `aa,(oldwo pm000p u Io sanlluluasaadaa le0al aq1 Suipnloui pule `astadaalua lurof g ut Pa Su ulo�aao3 atil JO glow ao onnl ,rule ao `,4pua 1r2al aaglo ao uotlgaodaoo `uotlletoossu `dltisaaulard `1rnpintpul ole„ St'paugap sr la,foldwa ud «•uautam ao luau poYldwi ao ssaadxa `aattijo loraluoo ,ruleaapun aatiloule 3o aolnaas oql ut uosaad CaaAa•••,, sr paugap s1 aadoldeua ule `aln;lels', slgl of lurnsmd •saa,toldwa atagl ao3 uoillesuadwoo �sa01.IO n apinoad of saa,Coidwa lie saalnbaa ZS i aaldlego sme-I Iwo a suasngorsslew suoijanilsui pue uoiliamiojuj N° / v 0 Date..... :Z °.:f�..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING .s This certifies that.,...-�:?-�.... L,,,�Y has permission to perform .:.. -! wiring in the building of .......................................................... at .r ?15...... ........................................ . North Andover, Mass. Fee rte........ Lic. No. RVJ.G. .......... ELECTRICAL INSPECTOR 07/22/99 13:18 35.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer � l �%P LIIYIITZiQIiIUPttjf� of Ft�13tttUSP13 Office Use OnPermit No. 17J10 +9e>partment of puhlir —Attfetg Occupancy & Fee Checked,i� BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank) U19-- ) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATJON) Date %- Z 0' q City or Town of /U • 4^f 10 0 L) f /F-- To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Number) 2 / Ab�121%G 12 S T - FORWARD Owner or Tenant 1 �G ` 0 S dy c--/,/ C �-- Owner's Address Is this permit in conjunction with a building permit: Yes CI No ❑ (Check Appropriate Box) Purpose of Building 4-Q S 4 I lUtility Authorization No. Existing Service Amps _� Volts Overhead ❑ Undgrnd ❑ No. of Meters i New Service Amps / Volts Overhead ❑ Undgrnd ❑ No. of Meters if Number of Feeders and Ampacity �1 Location and Nature of Proposed Electrical Work _ y I No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures _ Swimming Pool Above In- grnd. ❑ grnd. ❑ Generators KVA No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices No. of Self Contained Detection/Sounding Devices LocalMunicipal ❑ Other ❑ Connection No. of Ranges No. of Air Cond. Total tons No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of No. of Signs Ballasts Low Voltage Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: 46'6r!�� hf ✓ le? r /-I INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws 1 have a current Liability Insurance Policy including ComeleV Operations Coverage or its substantial equivalent. YES ANO G 1 have submitted valid proof of same to the Office. YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the apprlA ate box. INSURANCE Ci BOND ❑ OTHERQ❑ (Please Specify) Estimated Value of Electrical Work _$ / O Q f 61.0 Work to Start 7 7-.,)- 9 � Inspection Date Requested: Rough Signed under the Penaltiep of perjury: ^ , / ✓ /T/vT Final (Expiration Date) FIRM NAME �tJ / ! IF7IV f /T�� �t� Licensee —_.ea r' %�, U %I / V & q /�� /vim UC. NO. % �� �ry / gnature LIC. NO. 0 Address - 07^7 /�/ d la /! U �� C�(/I' P/�C•P %�(� Bus. Tel. No.i�a� - �0 8oZ— �7 �% ! Alt. Tel. No. OWNER'S_ INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) (Signature of Owner or Agent) Telephone No. PERMIT FEE $ x-6565 N2 1774 Date ...... �/7/A�yy - n. TOWN OF NORTH ANDOVER PERMIT FOR WIRING CN 0 E This certifies that e....... has permission to perform ...... WA.s.:.�OVO o wiring in the building of Cows orth at ........................... ............... Agdore, Mass. - 04 Fee ..�. Lic. No/��*�/**�*&*�r�*/—S ... .. - a ............... ELE C � � (q(qJ WHITE: Applicant CANARY: Building Dept. PINK: Treasurer TBE(19A YlOL AWE LT Ol' M'Y-SS4C(1U.aL: I office Use only DEPART7yfFNTOFPUBLICSAFETY Perron No.74 n y ���� ARD FNEPREVFVI70NREGCIL4TIONS527CMR 12.1X1 Occupancy &Fees Checked APPLICATIO FO TO P�R�OIzlVI ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT FN INK OR TYPE ALL rNFORMA TION) e 5//eA Town of MAP North Andover �T the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described belo • PARCEL Location (Street &, Number) 2-5 0,ig(Jz- D owner or Tenant ~3— 17- Owner's address J �%fOj ///R/U �/'�,� f. this permit in conjunction with a building permit: YesLAJ No (Check Appropriate Box) r� Pu ose ofBuilding BuildinUtility � b .quthorization No. Existing Service Amps / Volts Overhead Underground Q No. of:lleters New SelLvice Amps/:?a/ olts Overhead Underground � No. oflivteters i Number of Feeders and Ampaciry i Location and Nature of Proposed Electrical Work )IJ AfA No of Lighting Outlets :=, Tubs No. of Transformers Total K A No of Lignung Fixtures Swimming Pool Above Below Gencrators KVA around eround No of Receptaae Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No 01 Switch Outlets No. of Gas Bumers l/ FIRE ALARMS No. of Zones No of Rangcs No. of Air Cond, Total Tons No. of Detection and do of Dispos isr No. of Heat Total Total Pumas Tons KW o. of ng Devices No. of Sounding Devices No of Dtshwasners Space Arca Heating KW' t No, of Self Contained Detection/Sounding Devices Local � Municipal Connections � Other No of Dryers Heaung Devices K,V No of Wale. Heaters KW No. of No. of _ Suns Bailasis N'* H Gro ,`lassaet -uos No. of Motors Total HP i OTHER • � � / it � ��ti �._ �i Btr�es Tel Na Cis �c1G>e� l2a_?�'U y AiTaN11 O��'S i'NE`i,'RA?N� tiVANER;13 rt avare rt�c � Lim; � txi � tt� u�rarxxe oa�� a -as s,.'a�araia! e� as t�zci by i�+n-x+, w�*c Gr: � Laws and tl�.a rrrysi—spat this pests acp5=w wanes tics re4zs (Please check orae) Owner a Agent 11 1�.� Telephone No, PERMT T FE:. S Location ZS *ISG rG �(� J �67� 3 5 5 No. Date —� t NORTfI 1 TOWN OF NORTH ANDOVER a 3 - p Certificate of Occupancy $ O, —S s Building/Frame Permit Fee $ �'�s''„° •'<�' Foundation Permit Fee $ J CMUO Other Permit Fee $ Sewer Connection Fee C” Water Connection Fee $ /0Aco g_ TOTAL��,jj // $ oa ildinns actor ,y�! �-r7 ft.._ ,- � 9 il:Z6 1 Q00. .F.IC ��ld�,.("/ J ' K/i4�� Div. Public Works N0 1409 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. 19 Application by the undersigned is hereby made to connect with the town sewer main in /'© WY Street, subject to the rules and regulations of the Division of Public Works. / The premises are known as No. or subdivision lot no. Owner Contractor PERMIT TO CONNECT The Division of Public Works hereby grants permission to "n ( o/ /04? d'✓l t Address Address Applicant's Signature TH SEWER MAIN ICord ��� . L ile Street to make a connection with the sewer main at r—L r0 l Street subject to the rules and regulations of the Division of Public Works.. Inspected by Date Division of Public Works By See back for rules and regulations RULES AND REGULATIONS FOR GOVERNING THE INSTALLATION OF SEWER SERVICES 1. No unauthorized person shall uncover, make any connections with or opening into, use, alter, or disturb any public sewer or appurtenance thereof without first obtaining a written permit from the Division of Public Works. 2. All costs and expense incident to the installation and connections of the building sewer shall be borne by the owner. The owner shall indemnify the (town) from any loss or damage that may directly or indirectly be occasioned by the installation of the building sewer. 3. A separate and independent building sewer shall be provided for every building; except where one building stands at the rear of another on an interior lot and no private sewer is available or can be constructed to the rear building through an adjoining alley, court, yard, or driveway, the building sewer from the front building may be extended to the rear building and the whole considered as one building sewer. 4. Old building sewers may be used in connection with new buildings only when they are found, on examination and test by the (Superintendent), to meet all requirements of this ordinance. 5. The size, slope, alignment, materials of construction of a building sewer, and the methods to be used in excavating, placing of the pipe, jointing, testing, and backfilling the trench, shall all conform to the following requirements. The sewer shall be 6"diameter SDR 35, PVC pipe. Minimum slope shall be 1/8" per foot. The minimum depth of sewer shall be four feet below finish grade. Sewer pipe shall be installed on a stable trench bottom of hard durable crushed stone to a minimum (6) inch depth below the pipe. After the pipe has been installed, crushed stone shall be brought up to the crown of the pipe. Care shall be taken to carefully grade and compact the stone, and prevent pipe displacement. The remainder of the trench shall then be backfilled in one foot lifts with mechanical tamping after each lift. 6. Whenever possible, the building sewer shall be brought to the building at an elevation below the basement floor. In all buildings in which any building drain is too low to permit gravity flow to the public sewer, sanitary sewage carried by such building drain shall be lifted by an approved means and discharged to the building sewer. 7. No person shall make connection of roof downspouts, exterior foundation drains, or other sources of surface runoff or ground water to a building drain which in turn is connected directly or indirectly to a public sanitary sewer. 8. The applicant for the building sewer permit shall notify the (Superintendent) when the building sewer is ready for inspection and connection to the public sewer. The connection shall be made under the supervision of the (Superintendent) or his representative. 9. All excavations for building sewer installation shall be- adequately guarded with barricades and lights so as to protect the public from hazard. Streets, sidewalks, parkways, and other public property disturbed in the course of the work shall be restored in a manner satisfactory to the (town). w 0. M 9 G / ¢ 3 k �� c C Q aLIJ c�F z o � � 1 i- U a8 C. Z a a � N O O O � x F zIn ►. m p O O z m O z m o w rl cY, pp g O U r l N 4 Z w m V] 9 P4 Iz ¢ 3 0 �� c C Q aLIJ c�F o � 1 i- U a8 C. Z a a � N O O O F F F zIn ►. m p O U U o 2 p o O O O ° O z w w s o o z a a m m -F a m a c7 E V) V) w w F 'n w w n o g° z 0 z w m a V) V) V) P4 c V f c�F o � i- U C. Z � N 0 ►. U s a Yll ,\ w z o a O N- O ti � F v) F O a F, 9 z o n a �.j rn i o a Z v LT2¢ ¢ z O O w z o w a 2 p a C O O F� Z O z w v v ¢ z¢ m m p o o¢ cn cn c V f c�F lL_:J f i- U C. Z � N 1 ►. U L' ; a?xa� b'i��&S h11,G8 0,- 3 x l` 0'6 "'P = 31 S a o, �rar d I SOC (. = s�-P.0 r) C2 id as x02 - r) y-L-s6,000- l� �a 35.2 ��S � -t�� 950,- (.ZhmehJ'?ef+Gk 6XI(' SOO.- 1 3 'bl,380,' li Uw 10 C/� o 1619 r Z Y Z bcz I •XW % _ < 1 f * I .. Z < � 3 C z 3 C — z x I�j IPJ �, Z _ .� I ✓� � 5 Y W ::: J L - tQ K X K aLU j� uj z W (y N I I I Z � I i J V = 25 W z o L) � � C — u � IV) LIJ f V ^ w V V X ' Z k Z cc LL c L.0h ZZ cn N L = V Z 4 L Z , c v x cc j — Z N i 'n Z 'A ; — m — LU Z Q FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION* APPLICANT !' 690JY r0C-4)10�1 e2-7�c PHONE LOCATION: Assessors Map Number PARCEL_ SUBDIVISION _ LOT (S)1 /:AA ) �l STREET�U� ST. NUMBER �' ►,��*„**"t k************************ O F F I C IAL USE ONLY*************** Ono ENDATIONS OF TOWN AGENTS: . OqSERVATION ADMINISTRATOR COMMENTS AfU! TO PLANNER COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED_ FOOD INSPECTOR—HEALTH DATE APPROVED DATE REJECTED QRS W SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS lir.. )00' PUBLIC WORKS - SEWER/WATER CONNECTIONS tTl `'V -5-7—?"7 DRJJVEW�AY PERMIT {� —[ -.J W — !77 /� q FIRE DEPARTMENT ;1-�GJ,,-J RECEIVED BY BUILDING INSPECTOR DATE Growth Management Bylaw Exemption Statement Town of North Andover Building Department This form shall be used to assist the Building Department in their determination of exemptions under section 8.7.6 of the Town of North Andover Growth Management Bylaw. The building applicant shall provide all of the necessary inforrQption as requested below. Name of Applic nt on Building P 'rmit (below) Address of Property for Permit (below) u �s u AeQ 0_ S4 (v- c Map and Parcel: Purpose of Application (check below) Phone Number of Applicant: Single Family _ Two Family I the undersigned applicant for the above property attest that the attached building permit for which this form is completed does comply with the EXEMPTION section 8.7.6 of the North Andover Growth Management Bylaw. I also understand providing this form does not absolve me or any party to this permit from the requirements of obtaining other permits required prior to the issuance of the Building Permit. Further I understand that my interpretation of the EXEMPTION status is subject to review by the Building Department and is only officially accepted when the Building Permit iq issued. Based on section 8.7.6 of the North Andover Growth Bylaw the above lot and the work as applied for on the above lot, in the building permit application and associated attachments, complies with one or more of the following sections as indicated by a check mark. This is an application for a building permit for the enlargement. restoration, or reconstruction of a dwelling in existence as of the effective date of this by-law, provided that no additional residential unit is created. The lot(s) were/was created prior to May 6, 1996 are exempt from the provisions of this Section 8.7 of the Zoning Bylaw. This application is for dwelling units for low and/or moderate income families or individuals, where all of the conditions of 8.7.6.care met and/or represents Dwelling units for senior residents, where occupancy of the units is restricted to senior persons through a properly executed and recorded deed restriction running with the land. For purposes of this Section "senior" shall mean persons over the age of 55. This application is a part of a development project which voluntarily agreed to a minimum 40% permanent reduction in density, (buildable lots), below the density, (buildable lots), permitted under zoning and feasible given the environmental conditions of the tract, with the surplus land equal to at least ten buildable acres and permanently designated as open space and/or farmland. The land to be preserved shall be protected from development by an Agricultural Preservation Restriction, Conservation Restriction, dedication to the Town, or other similar mechanism approved by the Planning Board that will ensure its protection. This application represents a tract of land existing and not held by a Developer in common ownership with an adjacent parcel on the effective date of this Section 8.7 shall receive a one-time exemption from the Planned Growth Rate and Development Scheduling provisions for the purpose of constructing one single family dwelling unit an the parcel. CKThis application represents a lot which is ready for building permits,(i.e. all other permits from all other boards and missions have been received and the project is in compliance with those permits), and the Development Schedule does not accommodate issuing a building permit in that Year, one building permit will be issued per Year per Development until such time as the Development Schedule accommodates issuing building permits. Applicant must supply approved form U with this EXEMPTION. Please provide any and all information that would assist the Building Department in making a determination' that your application is allowed one or more of the above EXEMPTIONS. By signing below I attest to the accuracy of the information provided and that the attached building permit is allowed an EXEMPTION as cited above. Further I understand that the submittal of misleading and or inaccurate information, or the checking off of an above item which does not comply, whether done to my knowledge not, is gr hd r r sal by the Building Department to issue a Building Permit. 99, ignature or OWner or Aut nzed Ag t who signed the Attached Building Permit Date This form must be attached to the Building Permit upon application for such permit. APPLICATION FOR WATER SERVICE CONNECTION North Andover, Mass. -4,q 7 f 9 Application by the undersigned is hereby made to connect with the town water main in . ��LG Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. or subdivision lot no. 338 Owner Contractor d'v Street "175 -5752 Address Address Applicant's Signature PERMIT TO CONNECT WITH WATER MAIN The Board of Public Works hereby grants permission to m cz:'e-efl(L-p-2-5� k? C. to make a connection with the water main at "amu A(- /1) l CI Street subject to the rules and regulations of the Division of Public Works. Inspected by Date Board of Public Works By � Z(/ See back for rules and regulations RULES AND REGULATIONS GOVERNING THE INSTALLATION OF WATER SERVICES 1. No persons shall tap or in any way tamper with water mains which are part of the distribution system of the Town of North Andover without a valid permit from the Division of Public Works. 2. All water services shall be installed a minimum of five feet below the finish grade. 3. No water services shall be backfilled without inspection by a representative of the D.P.W.—Telephone 687-7964. 4. Service connections shall be 1" type k copper tubing. 5. All fittings shall be brass flange type Mueller or equal H 15202 Corporations H 15212 Curb stops H 15402 Three part unions H 8185 stop and waste valves 6. Curb boxes shall be installed at the property line and shall be of the Erie Type with 41/2 foot rod and brass plug type cover. GEORGE PERNA DIRECTOR TOWN OF NORTH ANDOVER, MASSACHUSETTS DIVISION OF PUBLIC WORKS 384 OSGOOD STREET, 01845 4" yts«eo OL O # A - y DRIVEWAY PERMIT Telephone (508) 685-0950 Fax (508) 688-9573 Date: M LOCATION: BUILDER: phone: OWNER: phone: e North Andover Superintendent of Highway Utilities & Operations MUST be notified of the ide and set -back from street established in any driveway entry onto any street or way maintained by TOWN. Call the Highway Superintendent's Office, before finish grading and surfacing for approval such entry. FAILURE TO COMPLY AND OBTAIN APPROVAL VOIDS THIS PERMIT Remarks: Approval: MASchec.k COMPLIANCE REPORT Massachusetts Energy Code MAScheck Software Version 2.p CITY: Lawrence STATE: Massachusetts HDD: 6235 CONSTRUCTION TYPE: 1 HEATING SYSTEM TYPE: DATE: 5-10-1999 DATE OF PLANS: or 2 family, detached Other (Non -Electric Resistance) TITLE: 25 Harold Street COMPANY INFORMATION: Belford Construction Co. Permit # Checked by/Date COMPLIANCE: PASSES Required UA = 265 Your Home = 252 Area or Insul Sheath Glazing/Door ------------------------------------------------------------------------------- Perimeter R -Value R -Value U -Value UA CEILINGS 1063 38.0 3.0 29 WALLS: Wood Frame, 16" O.C. 920 15.0 3.0 61 GLAZING: Windows or Doors 239 0.500 120 FLOORS: Over Unconditioned Space 880 19.0 42 HVAC EFFICIENCY: Furnace, ------------------------------------------------------------------------------- 95.0 AFUE COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 1250 of the design load as specified in sections 780CMR 1310 and J4_._4. Builder/Designer Dater �� y U L 59 I W W I l� O 4 = O • ^1 cd 101 3 0 H 3 a 10 1 z z o 27- 0 z z� M 0. z C ;, W rn LL v V: s QI v): U �) b cu C M cccn s 0. a- _ m Ln ocu L: 3 3: Ou 4" O }' Q L 1' E CL m C lu Ql cr Q `d 1` : (L, �► Q .r; H Q >'/�L p_ C vi t L E v Q x c .o � CU oc 0 m 0 c O V OQ A Co a W .2 O c0 L 4 C2- Cf M O = o n c C: U 00= A N LL- CU foo 4) n Ln m uj *-L-' O w- m Z o D u E.. c g o" -CD + c UI ` F— m O Z A U -10 w V) a V) P4 OWw z z ►,� Or - b o w o rL v r- U G w" 9 OR. a. o c� co ii a 04 v� 7 A u w a W o n: 4) cn G i i O U W z O o c� c u. W Q w w v 7 as z cn o o cn uml am •I M LJ O W O — = O Y/ m 1Ea� r lk y 4� � (� t gt N N E C—d Q : MM 'V✓ t o o CM xO m C = 2 0 o U CD y C Q C O s W E.N <� O: ,4 m 1. o of �5 0 ac=d%CID co O c,•�Z� o cv 2 H CM m ca y a= d 'c = m mr 3 N F- 0 h 1y m y WCD evt mL «. •N C O �... dt = 2 Z •`m � V V m C� _OD X �'�'_ a4 -m •I M LJ 2-9 i Maw�H to certify tha" 1%yertq " -sed frcm date of da4si t"deci o • ` o. a'!::n@ of an appezi T C N I1 1, Any appeai shall be file within (20) days after the date of filing of this notice in the office of the Town Clerk. NAME: Jean Fogarty ADDRESS: 33 Harold St. North Andover, MA 01845 NORTH ANDOVER U -)r; n ESSEX NORTH REGISTRY OF DEEDS LAWRENCE, MASS. 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Giles 50 Deer Meadow Road North Andover, Mass. i17� t2- .0 a5 175.00' TO MARBLEHEAD STREET "' S 85"00'00" W I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BYLAWS OF NORTH ANDOVER WHEN BUILT ,�� HAROLD STREET OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. H d.:h......,...,..�.,�,...,w.�...,s..a.,.,n_.n.......�..w.........e.J..�+n..ab.,�:,....................w.,.�.......<.+....-...�...�........,...,..e..w... - - -,..�.m......�..............,..•..d,s4::u....e.....�,�.�.s.�......,.,..,......,.......,,a.........._....... CERTIFICATE OF USE &OCCUPANCY Town of North Andover Building Permit Number 17 q Date THIS CERTIFIES THAT D THE BUILDING LOCATED ON o7S%y �PoycC (SI MAY BE OCCUPIED AS S 1"V 41e JA1ni 11 07 dfd// ZAC/IJIN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 04 CERTIFICATE ISSUED TO do ADDRESS Building Inspector Y Ir of O �ccm oil cc .� CDCD mmj r _ A� o 0 N N E c ,l %9 %*S`V) 2 RCD 4 OCO Cc cm A £E0 c m o � ® �Z'oj.gs o �CD D .0 _0CIO C2 ti O O 2��Z� c mN CL � •c Z o �- Co C3 F- 2 y��y m W ACLJ C3 L Q 10 0.2 N) d 0.. 0-0 x.Q H m .0.. O y y E CD L CL co C O CD CL CA 0 0 'a. CO2 O L) O C O \ O FN O A C-0 1-01 Z w O A co o chi c C4 cn cn CC of O �ccm oil cc .� CDCD mmj r _ A� o 0 N N E c ,l %9 %*S`V) 2 RCD 4 OCO Cc cm A £E0 c m o � ® �Z'oj.gs o �CD D .0 _0CIO C2 ti O O 2��Z� c mN CL � •c Z o �- Co C3 F- 2 y��y m W ACLJ C3 L Q 10 0.2 N) d 0.. 0-0 x.Q H m .0.. O y y E CD L CL co C O CD CL CA 0 0 'a. CO2 O L) O C i O 0 U) Lij crw w W 4-- r10RTij OF $6,9ti0 4_ 6 O` O t� �- J3 .^ O coc�wcwr wnca � ��SSAC HU`����y APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS/LOCATION OF PROPERTY:O fk1 C� l \A, DATE REQUESTED FILED/READY FOR INSPECTION /0- CLOSING 0 CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORKAND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE -INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE DQE ---S Na�MEET ALL APPLICABLE CODES. SIGNED f ROUTING CONSERVATION PLANNING DPW - WATER METER NOTE r, 0 V\ 6) V A-$ 4, th dy*4 ri Uyx DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO B TTAL OF THE OCCUPANCY INSPE TION REQUEST DPW Signature File: OC form revised 618!98 INT2 4.075 Date.✓`?�.- TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . S-! !�! < i! ..% ''� t''.............. has permission to perform ...�i. 'f .-•....f,�a.�-meq.-'�......... . plumbing in the buildings of .�i2T %'9 �`'. !-�...... . at • �• • • • ��`i'? ? �. .... , North Andover, Mass.- Fee/ ass:Fee/. Y..t ` . Lic.. No..Y.�... ..(��y...t J ` wLUMBING INSPECTOR WHITE -.0W IY% 14:44 CANARY:14*9 5W. PINK: Treasurer FORWARD ? (L-Ld MASSACHUSETTS (Type or print) NORTH ANDOVER, MASSACHUSETTS Building LocationoC� A-1 0-f PARCEL d 0 y !( Type of Occupancy c. r R PERMIT TO DO PLUMBING Date 2— Permit # J— Amount[ yfA �- New 13" Renovation Replacement 1:1 Plans Submitted Yes ❑ No FIXTURES • J • MMMMMMMMMMMMMMMMMMMMMMMM nnnnnnnnnnnnnn�nnnnnnnnn F11 -'al ,.• ©n©nnnnn�■nnnnnnnnnnnnnnnn MM mile, (Print or type)I Check ne: Certificate Installing Company Name 4A �l'f Iw Corp. 1904 Address •�. C %* CID u❑ Partner. �k..�•G►"GI AA nc83 � Business Telephone El Finn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ® Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 11 Agent 11 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 tate Pl bin e d Chapter 142 of the General Laws. By: Signa u�i Mcensea FlumSer Type of Plumbing License Title City/Town ice se i um er Master IT Journeyman APPROVED (OFFICE USE ONLY 3 2 1 G Date.. % py1..-. ?. S..... . „oHTti TOWN OF NORTH ANDOVER . ,s1ti�L PERMIT FOR GAS INSTALLATION O This certifies that . ..� .... 8. has permission for gas installation . . A in the buildings of . !`�!'%` �1�.!� 1 .�.�?`............. . at . ?� ..f. ?� . l �� ...? ..... , North Andover, Mass. Fee. Lic. No. J !�-....'.� GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MAPS d ? PARCEL f0RW- RD ?-� L MASSACHUSETTS UNUORM APPLICATON FOR PERMIT TO DO GAS FITTING Type or print) i Date NORTH ANDOVER, MASSACHUSETTS Building Locations ¢ r �_ Pen -nit # ` - Amount S ,n^ ; Owner's Name Y r ` S fV, k New E Renovation Replacement Plans Submitted (Print or type)/1 Name tt,g t ov Address C. Check one: Certificate Installing Company ffCorp. 41 nils ❑ Partner. - ,LoI / Wt A1— 61-631 Business Telephone 19 —? � Firm/Co. Name of Licensed Plumber or Gas Fitter 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 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. of Owner or Owner's Check one: 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 Bode an�hapt �fl General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber )0.3q?, M Gas Fitter Licese Number Ek"llaster ❑ Journeyman r' (Print or type)/1 Name tt,g t ov Address C. Check one: Certificate Installing Company ffCorp. 41 nils ❑ Partner. - ,LoI / Wt A1— 61-631 Business Telephone 19 —? � Firm/Co. Name of Licensed Plumber or Gas Fitter 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 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. of Owner or Owner's Check one: 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 Bode an�hapt �fl General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber )0.3q?, M Gas Fitter Licese Number Ek"llaster ❑ Journeyman