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Miscellaneous - 25 MASSACHUSETTS AVENUE 4/30/2018
�ENVIRONMENT Lam,. August 22, 2006 City of North Andover 1600 Osgood St. North Andover, MA 01845 181 Canal Street, Suite 303 Lawrence, MA 01840 Voice: (978) 681-7888 Fax: (978) 681-8474 www.esourcecorp.net Here is a copy of the notification that you requested for your records. If you have any questions please feel free to contact me at 978-681-7888. kEGEIvE® AUG 2 4 2006 TOHEALTH DEPARTMENT ANDOVER AUG 2 3 2006 TOWN F din ntALTH DEPgR MOVER Massachusetts Department of Environmental Protection i eDEP Transaction Copy Here is the file you requested for your records. To retain a copy of this file you must save and/or print. Username: ESOURCE Transaction ID: 82568 Document: BWP - Asbestos Notification Form Size of File: 125.846 K Status of Transaction: SUBMITTED Date and Time Created: 8/17/2006::12:45:34 PM Note: This file only includes forms that were part of your transaction as of the date and time indicated above. If you need a more current copy of your transaction, return to eDEP and select to "Download a Copy" from the Current Submittals page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. INSTRUCTIONS Commonwealth of Massachusetts Asbestos Notification Form ANF -001 A. Asbestos Abatement Description 100037295 - .1_...W Decal Number a. Is this facility fee exempt - city, town, district, municipal housing authority, owner -occupied residence of four units or less? M Yes ❑ No b. Provide blanket decal number if applicable: 2. Facility Location: RESIDENTIAL HOUSE a. Name of Facilit LAWRENCE MA c. City/Town d. State 3. Worksite Location: 1. All sections of this form must be completed in order to comply with 4. DEP notification requirements of 310 CMR 7.15 5• and the Division of Occupational Safety (DOS) notification requirements of 453 CMR 6.12 6. 7. 8. 9. Blanket Decal Number [25 MASSACHUSETTS AVENUE�� b. Street Address 01843 786827890 e. Zip Code f. Telephone Number - BASEMENT ��J BASEMENT .. a. Building Name/Building Location b.'Building # c. Wing d. Floor e. Room Is the facility occupied? o Yes E] No Asbestos Contractor: ENVIRONMENTAL SOURCE a. Name 01840 LAWRENCE CiM„_ gown d. Zig„Code ka AC000649 f. DOS License Number JIM MCMURRY HECTOR B GUERRA INORTEAST ENVIRONMENTAL I INORTEAST ENVIRONMENTAL I 1/2006 7AM-4PM c. Work hour 10. a. What type of project is this? [] Demolition 0 Renovation ✓� Repair (] Other, please specify: 11. a. Check abatement procedures: E] Glove bag 21 Enclosure [l Cleanup Full containment Encapsulation Disposal only Ej Other, specify: 181 CANAL ST, 3RD FL ��== b. Address 9783817888 �� ..�....._,..,.. e. Telephone Number g. Contract Type: 0 Written E] Verbal i. Contact Per AS000637 b. § rvisorl AA000153 E Pro'e—q—mo i AA000153 F Asbestos A 8/12/2006 b. -End Date 7AM-4PM d. Work hour: b. Describe b. Describe 12. Is the job being conducted: Z✓ Indoors? 0 Outdoors? 0 anf001ap.doc • 10/02 Asbestos Notification Form • Page 1 of 3 0 Commonwealth of Massachusetts _ ■ 100037295 Asbestos Notification Form ANF -001 Decal Number Ll A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or encs sulated: 340 Co�a .Total pipes or ducts inear I o'Efier su'"'fii aces square c. Boiler, breaching, duct, tank 340 ASBESTOSINSPECTOR "— +Sq. surface coatings Lin. ft. Sq. ft. d. Insulating cement Lin. ft e. Name of DOS Official 8/10/2006 e. Corrugated or layered paper =L_ h. DOS Waiver # 0 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? Yes No L__ ... pipe insulation Lin. ft. Sq. ft. f. Trowel/Sprayer coatings _.J WLin. ft. -1 Sq. ft. —o 2. Is the facility owner -occupied residential with 4 units or less? C✓; Yes El No JIM MCMURRY 25 MASSACHUSETTS AVE--� 3' a. Facility Owner Name LAWRENCE—� b. Address 01843 1978-682-7890 g. Spray -on fireproofing Lin- SqL ft. — h. Transite board, wall board Lin. �Z 4' a. Name of Facility Owner's On -Site Manager b. On -Site Manager Address Z7777771 E:== I �Q c. City/Town d. Zip Code e. Telephone Number (area code and extension) ■ anf001 ap.doc • 10/02 i. Cloths, woven fabrics, ----J= Lin. ft. C!:�D j. Other, please specify: Lin. ft S9: ft k. Thermal, solid core pipe insulation mmr Lin. ft. Sa. ft. I. Specify 14. Describe the decontamination system(s) to be used: THREE -CHAMBERED DECONTAMINATION SYSTEM 15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (a): ACM WILL BE WET (HAND TO BAG). ACM WILL BE LABELED, PACKAGED 8r TRANSPORTED 16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency: JIM JORDAN ASBESTOSINSPECTOR a. Name of DEP Official b. Title 8/10/2006 0608965 c. Date (mm/(Jd/yyyy) of Authorization GARY GASPER�ASBESTOS d. DEP Waiver # _ INSPECTOR e. Name of DOS Official 8/10/2006 f. DOS Official Title _ 06277N6 g. Date (mm/dd/yyyy) of Authorization N h. DOS Waiver # 0 17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? Yes No B. Facility Description RESIDENTIAL HOUSE r _o 1. Current or prior use of facility: —o 2. Is the facility owner -occupied residential with 4 units or less? C✓; Yes El No JIM MCMURRY 25 MASSACHUSETTS AVE--� 3' a. Facility Owner Name LAWRENCE—� b. Address 01843 1978-682-7890 o c. City/Town d. Zip Code e. Telephone Number area code and extension L �Z 4' a. Name of Facility Owner's On -Site Manager b. On -Site Manager Address Z7777771 E:== I �Q c. City/Town d. Zip Code e. Telephone Number (area code and extension) ■ anf001 ap.doc • 10/02 Asbestos Notification Form • Page 2 of 3 ■ Note: Transfer Stations must comply with the Solid Waste Division Regulations 310 CMR 19.000 Commonwealth of Massachusetts Asbestos Notification Form ANF -001 B. Facility Description (cont.) 5. a. Name of General Contractor L__. c. Citv/Town d. Zia Code f. Contractor's Worker's Comp. Insurer 6. What is the size of this facility? 100037295 Decal Number b. Address e. Telephone Number area code and extension Policy Number w h. Exp.,Date (mm/dd/yyyy) a. Square Feet b. Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos -containing material from site to temporary storage site (if necessary): APOLLO ENVIRONMENTAL & DEMOLITION a. Name of Transporter DERRY 03038 c. City/Town d. Zip Code 2. Transporter of asbestos -containing waste material INA I _. a. Name of Transporter c. Position/Title __� j= 9786817888 ENVIRON. SOURCE COR d Zip Code LCitylTown 3. A 181 CANAL STREET, 3RD FLOOR a. Refuse Transfer Station and Owner c. Cit /Town d. Zip Code 4. IMINERVA ENTERPRISES INC __.. i. Zip Code a. Final Disposal Site Location Name 9000 MINERVA ROAD c. Final Disposal Site Address OH 44688 e. State N� f. Zip Code D. Certification The undersigned hereby states, under the penalties of perjury, that he/she has read the Commonwealth of Massachusetts regulations for the Removal, Containment or Encapsulation of Asbestos, 453 CMR 6.00 and 310 CMR 7.15, and that the information contained in this notification is true and correct to the best of his/her knowledge and belief. 33 A NUT HILL ROAD b. Address 603 4857554 e. Telephone Number from removal/temporary site to final disposal site: b. Address i__-_,_,_________- _ e. Telephone Number b. Address g. Telephone Number JOSE PENA� JOSEPPENA a. Name MANAGER b. Authorized Signature� 08/11/2006 c. Position/Title d. Date mm/dd/vvvv 9786817888 ENVIRON. SOURCE COR e. Telephone Number f. Re resentin 181 CANAL STREET, 3RD FLOOR Q. Address 01840 LAWRENCE�_ � h. City/Town __.. i. Zip Code E anf001ap.doc • 10/02 Asbestos Notification Form • Page 3 of 3 0 Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 CLCAT@CL-NA.COM Facsimile (214) 488-6766 ***********************AUTO**3-DIGIT 018 756 T3 P1 95000058946 Building Commissioner or Inspector of Buildings 120 MAIN STREET { N ANDOVER, MA 01845 Cunnin ham �% Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B 1593329 1593329 22 MERRIMACK MUTUAL FIRE INS ICE DAM 2/23/2015 JAMES & CLAUDETTE MCMURRAY 25 MASS AVE 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 313 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. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions,to a, building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A,.or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Claim Number: Policy Number: Company Name: 0) m Cause of Loss: co LO g Date of Loss: Insured: 0 Property Location Cunnin ham �% Lindsey Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B 1593329 1593329 22 MERRIMACK MUTUAL FIRE INS ICE DAM 2/23/2015 JAMES & CLAUDETTE MCMURRAY 25 MASS AVE 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 313 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. Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions,to a, building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A,.or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat(@cl-na.com 800-867-3885 10761 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Ak ............. .. .... .. ..................... ....... ; ............................... C3 has permission to perform ..... plumbing in the buildings of ...... I ...... I . . .............. . A f�---[) .......... at ...A .. I.- ...... '5...C.. e .................................. North Andover, Mass. Feeo ........ Lic. No.5S5... . ................................................................................. PLUMBING INSPECTOR Check,, 6ps- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGf WORK CITY . i MA DATEI PERMIT # JOBSITE ADDRESS { OWNER'S NAMEL' OWNER ADDRESS TED__JIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Ed PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: t PLANS SUBMITTED: YES NO FIXTURES 1 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 I; i I ; .� I ! � __.._..__.J _._ f ( E _ DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM ! ( I ._--_ I __. f I ! _._._) I I i I _-_- ._( I I DEDICATED WATER RECYCLE SYSTEM DISHWASHER .__..__,! DRINKING FOUNTAIN (- - ----' I J FOOD DISPOSER FLOOR/AREA DRAIN 1 __....:_1 I i ._._-1 l J I (-___-_I -_.....,_I INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY _ I _._.__.I ..___._ ([------1.i---__.I .._..J ROOF DRAIN (J ......._._! ..__— f i J i:I _-- _-- i SHOWER STALL _ _( .-...___I .--_-...J .___.--.-_ _...__,J _ _.___J .___.-_f _.-.__I _ .-.._' ._ .___I __.._....__! SERVICE/ MOP SINK ` . I ...:( _._.._.. .._,.__.1 _._..._._f -, I __._.._f 1 % f _. __._.( I ED TOILET-- URINAL WASHING MACHINE CONNECTION i WATER HEATER ALL TYPES WATER PIPING OTHER ,r t i i _.._a __ -- .._i __.-----i .. - --.i _.._._._I ( i _1=,= —j INSURANCE COVERAGE: I have liabili insurance its Ch. 142. 'NO 01 a current policy or substantial equivalent which meets the requirements of MGL YES.[ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF INDEMNITY —i 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 a 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 tru nd accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lance with all P ment vis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE # _- SIGNATURE MP [id JP_i CORPORATION . # _ .+ PARTNERSHIP 0# ' LLC 0 , COMPANY NAME d ��� ,d _ ` DRESS D,��ht1 R� UNIT_ /D CITY ,�% - - -; STATE , a ZIP Q1 - --- TELFAX $ UELL �. ; EMAIL a _ oveh .__Iclta,�(j;n- ct _ r► 4i,(�! O o Z wa t� The Conimonwealkh of Massachusetts Deparhnent of lndustriat Accidents Office ofInvesdgations - 600 Washing ton Street Boston, MA 02111 `v'r M4VW.rrzas&eoV1fill Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers Ay® licant Information - Please Pr€�t Leziblv Name (Business/Oraanizabou&dividual): �,/J�� G.l%f�,/���� Cif Address: City/State/Zip: Phone #: Are on an employer? Check the appropriate boa: Type of project (required):- 1. (% -I am a employer wi#h � . ❑ I am a generat contractor and I 6. Q New ctmstructicm employees (lull and/orpart time) have hired the sub -contractors 1. Q I am a sole proprietor or partner- :. listed on tbLe attached sheet i 7. n Remode ' g ship and have no employees These sub --contractors have 8. ❑ Demolition working for mein any capacity. [No vv dMrs' MBP ksmm workers' comp. insurance. 5. cc%pomtim and its g. Q Building addition required..] - officers have exercised their 10.0 Electrical repairs or additions .. Q I am a homeowner doing all work right of exemption per MGL 1 i . 5J Plutnbbg repairs or additions myself [No workers' comp. c.152, § IN, and we have no 12 -El Roof repairs insurance required.] t employees. [No workers' I3.[] Other comp.Insurance requireed.] 6y'u0!!ey r Iiomeowaes who stwmiifais aiadavit indicatiagihey axe doing aIi wort; and thea hire outside contract= must submit anew affidavit indicating sucu. !Contractors ff= chectc this box must attached an adamonat sheet showing tine name ofthe sib -contort= and their workers' comp. policy infoxmauoc. .£arae an employer that is providing workerscoMpensaYion insaarance for my employees below is the poticlr and job sue infnrmarion. Insurdnce Co#iny Name:, Policy :�P or Self -ins. Lic. T Sob Site Address: o,�ss� ' City/State/Tip: A4 Attach a copy of the workers' compensation policy'declaration page (showing the policy cumber cad e�siz anon trate). Failure to secure coverage as required uncle-, Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civiil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against Bre violator. Be advised that a copy of this statement may be forwarded to the Office of :uvesdgadons of the DIA for mmn-ane- coee'agaB veafficmon. I de hereby certify-ru&6 the pains arzderwltief that the information provided above is true and correct 0�°3R O,t —ia[ use on r. Bro not write in dds area to-heby city or town o,ffcial City or Town: Permitil icense Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone - w Information ation and Instrueflons t Massachusetts General Laws chapter 152 requires all -employers to provide workers' compensation for flies employees. Pursuant to this stature, an employee is def as "_.every pe?non in ffie service of another under anyconfratt of hue, express or implied, Dial or_written." An employer is defined as "an individual, partnership, association, corporation orotherlegai entity, or any two or more of the foregoing engaged in a joint enterprise, and including f1he legal representatives of a deceased employer, or flee receiver or trustee of an individual, pmtozrship, association ox- other legal entity, emplaying employees. However the —owner of a dwelling house having not more than ib= apartmLents 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 iyuulding appurtenant thereto shall not because of such employment be. deemed to be an employer." MOL chapter 152, MC(6) also states that "every state or local ficensiag agency shall withhold the issusace'or renewal of a license -or permit to operate a business or to manstruet bufidings in fhe commonwealth for any applicant who has not produced acceptable evidence of ceimpIiance with the insurance coverage requwed_ ' AdditionZy, MGL chaptm-152, §25C(7) states "Neuer the commonwealth nor any of its political subdivisions shall enter into any contract for the perfonnance of public work inxtil acceptable evidence of compliance with the insurance requirements of this chapter have bem presented to the cogra.cting au&ority." ,Applicants _ Please fill out tine workers' compensation affidavit completel:►, by checking the boxes that apply to your situation and, if : neressary, supply sub -contractors) name(s), addmss(es) and phone mumber(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Lieubflity Partnerships (LLP) with no employees -other than the members or partners, are not required to cagy workers° compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised Slat this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be stare to sign and date the affidavit. The affidavit should be rehmned to the c� ar trswn t =t the application fur `he pE a ziit-01 lire 1s being r-Auesbed, leo: lie Depai1=e et of Fndestnal Accidents. Mould you. have any c—pestions rega.rdi g the law or if you are requited. to .obtain a wor'xers' compensationpolioy, please call The Department at the number listed below_ . Self-insured companies should entertheir self-insurance license number on the appropriate line. - City or Town Of cial& Please be sure that the affida-vit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to IM out in the event 1he Office, of Investigati= has is contact you regarding fie applicant' Please be -sure to fill is the pemiWEcs se mimber which wM 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 wee "all locations is (city or t)wn)," A copy of the affidavit tical: has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit ism file for fiamEeperzaits or licenses. Anew affidavit must be filed out each year. Where ahome owner or citizen is obtaining a license or permit notrelated to anybusiness.or commercial. venture (Le. a dog license or penmt to bum leaves etc_) said person is NOT required to complete this affidavit. _ The Of cifInvestigations would like io ilraa3 you in advance f6r your cooperation and. should you have, any questions, please do nothesiiate to give us a call The DepartmeWs address, telephone and fax number: o -'o .� -- : , 3 iso 4. f . 1".. o �i3 Y, :,.,a o 7 :e is d ' f TeL # 6.17 727-490a.eg406 or 1-877 MASSAFE Fax # 617-727-7749 Revised 5-26-05 yirwwmassgovfdia 11y OP ID: CHCR A`., "r CERTIFICATE OF LIABILITY INSURANCE DATE{M2/1YYY) 10/222/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemengs). PRODUCER Phone: 978-688-6921 Macdonald & Pangione Insurance P.O. Box 428 Fax: 978-688-5350 104 Maitreet n S North Andover, MA 01845 CraigS Childs cAOpNpEACT PHONE FAX aC No Ext):(AIC' A/c No): E-MAIL ADDRESS: PRODUCER CUSTOMER ID #: ANDOV-7 INSURER(S) AFFORDING COVERAGE NAIC 0 INSURED Andover Plumbing & Heating Co. PO Box 262 Andover, MA 1 INSURERA:UtiCa Mutual Insurance Co INSURERB:Quincy Mutual Fire Ins Co 15067 -INSURERC: INSURER D: X COMMERCIAL GENERAL LIABILITY 1 CLAIMS -MADE D OCCUR • INSURER E : INSURER F - 10/26/13 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: ` THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF MMID POLICY EXP MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY 1 CLAIMS -MADE D OCCUR • 4481325 10/26/13 10126/14 DAMAGE ToRENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,00 PERSONAL& ADV INJURY $ 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,00 .-X1 POLICY JECT F] PRO - FLOC $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ B SCHEDULEDAUTOS I HIRED AUTOS AFV206229 10/26/13 10/26/14 PROPERTY DAMAGE (Per accident) $ S NON -OWNED AUTOS $ X UMBRELLA LUIB X OCCUR EACH OCCURRENCE $ 1,000,00 A EXCESS LIAB CLAIMS -MADE CULP 448141 10/26/13 10/26/14 AGGREGATE $ 1,000,00 DEDUCTIBLE $ $ RETENTION S WORKERS COMPENSATION WC STATU- OTH- I X I A AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE4481326 OFFICERIMEMBER EXCLUDED? E-1 N / A 10126113 10/26114 TORY LIMITS ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 (Mandatory in NH) Ups descr be under DESCRIPTION OF OPERATIONS below E -L DISEASE - POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Plumbing and Heating contractor X -114M -1•1-4.I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Plumbing & Gas Inspector Building Dept 1600 Osgood St Bldg 20 #2-36 AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD v L � b ISSUES TH1= FOLLOW NS-E:D AS A MAS GE. G€ R M`EE4UN 4 4 o 1844-423':3 223429 This certifies that has permission for. gas Date... .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 2.A CY,.4?1) ....... ....... ..........� i. G- ...... . ....................................................... in the buildings of ... I ....... 1 '*-,(0— A-- ........... ..... ), . . . .......................................... at .......... 7?2 ........ M.1 A.. f .......................... North Andover, Mass. Fee.... ... Lic. N0 .15 ... .................................................................... Pf GAS INSPECTOR Check # 9550 �'� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Od MA DATE / PERMIT # JOBSITE ADDRESS OWNER'S NAME G, OWNER ADDRESS TE -- D FAX L — TYPE OR OCCUPANCY TYPE COMMERCIAL [-J] EDUCATIONAL ® RESIDENTIAL Q/ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NOEJ APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I f I I I .. BOOSTER CONVERSION BURNER —j _ COOK STOVE J _ DIRECT VENT HEATER I I I I DRYER FIREPLACE FRYOLATOR FURNACE _t h J - _ _ _ _ .- 1__ --._-- GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ . Imo. II ( _ _ — _ -_ OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATERrl �_— UNVENTED ROOM HEATER WATER HEATER OTHER L.21 --_--j I. -- _-.. ..... INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES [0/N'0 0 IFIU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY © BOND n 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 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true an ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliarjoig with all Pertine r visi Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME d� LICENSE # 3_ SIGNATURE —Dh� - MP [( MGF Ej JP L11 JGF Q LPGI CORPORATION [+' # a�v -_ PARTNERSHIP 0# LLC 0-1# COMPANY NAME •d�_ _ ' DDRESS .O____.& CITY /�% 11 _— _ _A _ _ STATE M ZIP0,-/W _ TEL FAX CELL _ , EMAIL al9C�Ol��'/-lJ�fl]__j� Rr� qm i • Co __ _ ` on z W IL ui LU LL /11i The Co-Tua nwealth of Massachusetts Department ofIrr Austrial Accidents Office of lavesikadons 600 Washington Street ` Boston, AIA 02111 www.rrzasagovIdia Workers' Compensation Insurance Affidavit: Buffders/Contractors/FIectricians/Flumbers AuoIicant Information Please Print Ledbh Name (Business/Oraannation&dividual): Address:��T/'r City/State/Zip: ��r1 /%�" D%�'y Phone #: Are ou an employer?. Check the a ro rate boa: . P .. �'PP i Type of project (required):" 1. [0 -I am a employer -with 4.] I am a general contractor and I 6. ❑ New consttuctitm employees (full and/orpart-time).* 2. Q 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. E] Demolition worlang for me in any capacity. �To wodcere comp inst�ce workers' comp. insurance. { We a : poratian Irl its 9. [] Building addition required.] ❑ officers have exercised their right 10.Q Electrical repairs or additions 11.561umbing � . I am a homeowner doing all work of exemption per MGL repairs or additions comp. myself [No workers' co c.152, §1(4) and we have no � I2.� Roofrepairs ins►,ra„ce required.] t employees. [No workers' 13.0 Other c9mp. msura +ce required.] !1Lst. a, so rM. 0-a-Eie.: leaden .._:! e^.oW!.^.b�.^:- 8r^Ti.^5'=�^....u. 4.�. LO:1 :.1or'mahM3.. T Homeowners who submittnis amdavit indwating ley are doing all wort: and $ea biro outside contractors must submit anew affidavit indicaiina such. +Contractor that check this box must attached an a6ffdonat she --t showing the name ofthe sub -contractors and their workers' comp. policy i nformanm rant an employer thug is providing worbers' compensation ansaarance for my employees Below is the policy and job sire informafiors h=,iuce Combing Name: Policy _ or Sell ins. Lic. Expiration Date: Job Site Address: /G'/ City/State/Zip: /IW 2/ we Aftaeh a copy of the workers' compensation policy declaration page (sho;ving the policy number and expiration date). Failure. to secure coverage as required undo-. Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a line up to $1,500.00 and/or one-year imprisonmeM as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.100 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ofnce of vesttgations of the DL4 i'or i mnznc-- coverage verificamon- I do hereby certify o der the pains arzd perz¢itz�* oar thrat the informmYrin provided aboyye is true acrd correct 6JTw&Cuse oruy. Do nor write in this area to Iseeom by cup or town of w- &i City or Town: PermitlUcense Issuing Authority (circle one): 1. Board of Health 2. Build4ne. (Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Contact Person: Phone v 1 Information and Instructions Massachusetts GeneralLaws chapter 152 requires all employers m provide workers' compensation forlreir employees. Pursuant to this statute, an em 'is defined as "...every pe--non-mi fie service of another under any contract of hire, express or implied, oral or written." ' An employer is defined as "an mdividnal, partnership, associmlion, corporation or•othmlegal entity, or any two or more. of the foregoing engaged In a jointenterprise, and including f1he legal representatives of a deceased employer, or the receiver or trustee of an individual, pant rship, association oz- other legal entity, employing employers. However the owner of a dwelling hoose having not more than three aparim.enis and who resides therein, or the occupant of the dwelling house of another who employs persons to do mamteaance, construction or repair work on such dwelli� house or on tare grounds or bolding appurtenantthereto shall notbecrose of such employment be deemed to be an employer"" MOL chapter 132,' § C(6) also sfa#es that "every state or local licensingmaty shalt withhold the issusince'or renewal of a Iicense-or permit to operate a bushms or do menstruct buildings is gine commonwealth for any . applicant who has not produced acceptable evidence of comapliiance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states ` Neither the commonwealth nor any of its political subdivisions shall enter Into any contract for the performance of public work irn1il. acceptable evidence of campH=ce with the insurance requirements of tins chapter have been presented to the contracting authority." .Applicants '_ . • -_' - _ . Please fill out the workers' compensation affidavit complabd3r, by checking the boxes that apply to your sitzmiion and, if neressa y, supply sub-coniractor(s) name(s), addresses) and phone numbers) along with their certificate(s) of insurance. I imiUed Liability Companies (LLC) or Limited Liability partnerships (LLP) witkno employees -other than the members or par(ners, are not required to carry workers' compensation insurance. If an LLC•or LLP does have employees, a policy is mqun-ed. Be advised Out this affidavit may be submitted to t"b Department of ludashial Accidents for confizmation of insurance coverage. Also be sure to sign and date the affidavit Tire affidavit should bo returned to the City Or trrrM IU4= fire applsca f ih= p it of lienee is being r gaest~d, no: foe D=artmmt of Industrial Accidents. Sould you have any ,questions regarding tlm taw or if you are required tD .obtain a won'mrs' compensation police, 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 aiitdavit is complete and printed Iegibly. The Department has provided a- space at the bottom of the affidavit for yon to Fill out In the event the Office of Investigatiow has to contact you regarding the applicant.• Pleasebe, sure in fill in the pe nitlL+'c- use number which wM be -used as a reference mrmber. In addition; an applicant that must submit multiple pmmit/Iieense applications In any given year, need only submit one affidavit indicating current policy information Cif necessary) and under "Job Site Address" the applicant should wr!fe "all locations m. (city or town)." A copy of time affidavit brat has been of stamped or marked by the city or town may be provided toft applicant as proof that a valid affidavit is on file fear f tueperrnits or licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a lic ewo or permit not related to anybusiness.or commercial venture (i.e. a dog license or pemoit tD bum leaves err;.) said person is NOT required to compktE this affidavit - The Office of Iuvestigations would 10m is ft* you in advance for your cooperation aud. should you have any questions,. please do not hesitate to give us a call. The Departmees address, telephone and fax number: a a at tl f 9 to :q a i • ti.. ® - the / '-a .t -tat M.39)1100 i 76 i TeL # 617-727-4900-ad406or 1-877 MASSAFE Revised 5-26-05 Paz m 61-7-727-7749 usww- mass govfdia Date .. �). h .6....... . 3jory�,...o ,e"e oL TOWN OF NORTH ANDOVER O � 9 • PERMIT FOR GAS INSTALLATION SACNUS � ^_ This certifies that 4 ............ has permission for gas installation e ,f t. /P . J c ZI.... . in the buildings, of /X� c. /;I/ � �.IV ....................... at . J. .. `#.f,E? .� t..�4.--�........... , North Andover, Mass. Fee ... K. k.. Lic. No...�' G S INSPECTOR / Check # t �od U_s (Type or print) Date Spn 7 2,007 NORTH ANDOVIM MASSACHUSETTS 25 Mass. Ave. Pennk# Building � S7 Amount S _ Ow�sNO" James McMurray New ❑ Renovation ❑ RI1t Plm>s Submitted ❑ B. FLOOR Andover- Plumbing & Heating Co Inc Corp.Addvas 20 AeQean Dr Unit #10 _ ❑ Partner: Methuen, Ka 0 844 NsecfLk=r dPhm*wcrGwFmf - George Larose BOUItAN CE CDVEL49M G'Ledc am 1hucar, t Tpdkywjrs=bmwdav Yes Q Nu[ IfyDnhied wclwd3AmL 901W Fla @I byd=V=dw bm Lieb tyiao®ermocePeft citbe>wrtypaaf ► 13Bond [j owmeshmmomwahm I by I420£&e Mass. ce�a�is�,ana�.cs�►oo�p�ic�adas.ahe��is jSISmV C6ea�mG neof0smwar0wmesASW os nes ❑ A ❑ . i haft caftibmtAmfdedeIsmdi dhm" aIhav submitled(aradmaGitsba-aappGrAfimmml eaadaocmafetothe bodafmplmowieVadddmtas I Ii SWO&And ammerramam=mwr=Bvm Dem co ewm8l, armeaaiptovieiooeafdel -PsQ0lcaod .l42CaaaaiLaws. CasFi�er Date. . 10n,140 A., TOWN OF ORTH ANDOVER dERMTOR PLUMBING ,SSACMUS This certifies that ... has permission to perform ...... ....................... plumbing in the buildings of ... � /�. '/ .............. — I .-.. North Andover, Mass. at. . .). ) ; ' i� .� ... 1/1 C - Fee. Lic. No.z.?J• -1 .. ............. PLUfNBING INSPECTOR Check # dl 7099 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Sent_7.2006 Building Location 25 Mass Ave Owners Name dames McMurray Permit#_ !) 049 Amount h_ti Type of Occupancy Residential New 0 Renovation ❑ Replacement d Plans Submitted Yes ❑ No FIXTURES (Print or type) Installing Company Name Andover Plumbing R HPati ng rn . Tnr Address 20 Aegean Dr. Unit #10 Business Telephone (q7g) F.Rq,_S2jS2j Che one: Corp. 2122 UPartner. , 11 Firm/Co. Name of Licensed Plumber. George Larose Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity11Bond ❑ Certificate 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 El 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 Massach tate Plumbin de h 142 of the General Laws. ZOO. - By: Signature ot McWwuum er Type of Plumbing License Title 9983 r City/Town License um er Master ' ✓( Joumeyman ❑ APPROVED (OFFICE USE ONLY 1: Date...... 7n./.Z7'ph TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that........ C ............ A J .....t -.L....5 ...................... has permission to perform wiring in the building of ........... ........... I .............................. K/e .................. v at ......... .... ...... !!m4eF ...................... North Andovei, Mass. Fee ..... Lic. No. ........ t A - INSPECTOR Check # 6787 (flIminonweaIg of Maseac%ueelle _ ,parlmen/,l ire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 7O 7 Occupancy and Fee Checked &/Z— Rev. 11/991 (Icave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NIEC), 527 CNIR 12.00 (PLEASE PRIiVT 1/V INK OR TYPE ,4 LL /r 0/Z.LL-17/ON On (c: q .-3 -- Q 6 City or "Down of: rA o �� �� To the Inspector of Wires, - By this application the undersigned gives notice of his or her uuentiou to perform the electrical work described below. Location (Street & Number) d S S g Owner or Tenant ' s ('y\el-frl Telephone No. Sp Zr-- I40 Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building- ` Utility Authorization No. Existing Service Amps / 1'olts Overhead ❑ Uudurd ❑ No. of Meters _ New Service 2-0 Amps (7-0 /Z40 Wolfs Overhead Undgrd ❑ No. of Meters Number of Feeders and Am achy �r�S�"� P ��.i 1 Yom.' a aS c c�/� Location and Nature of Proposed Elleectrical.\}'ork:_; 4' C -y -i` t Ci o Completion oldie %llou-ine table maybe u-nih•r,l h,• it,/,.� iv:..... No. of Recessed Fixtures No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of ilut Tubs Generators KVA No. of Lighting Fixtures (p b b Shimming Pool Above n lir- ❑ b arid. grp.d. t o. o mergenc}, rg Lung Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALAJZNIS jNo. of Zor:es No. of Switches 2L ---- No. of Gas Burners ,- -- No. of Detection and Initiating Devices No. of Ra rafalnges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers _ Heat Putrrp Totals: Number 'I ons KNV tNo. of elf- ontaitled Detectiori/Alerting Devices I _ Nu. of Dishtirashers S ace/Area Heatin KW p g Loca! ltilunncipal Othe Connection ❑ r No. of Dryers 1 Appliances Heating A HeatPP IC\\ Security Systems: No. of Devices or Equivalent No. of Water Ilealcrs K No. of N0. 61z Ballasts Signs �- - Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total IIP l-elecommunications `ti•iring: No. of Devices or E uivalent OTHER: Attach additional detail ifdesired. or as required by the Inspector of tires. INSUR UNCE CON` EIU%GE: 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 ruuhorsi!.ned certifies that such c7BOND e is in force, and has expermit exhibited proof of same to the issuing office. CHECK; ONE: 1NSUR1\NCE ❑ O-l"HER ❑ (Specify:) g-3 ` —Q (Expiration Date) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, «rider the pains and pen allies o perjtu)•, that dee information on this application is trite and complete. e1 � FIRM NAME: G + 6 C� LIC. N6. I'S 4.4 Lice nsee:Qj Signature LIC. NO.:'k k &=�� (/f applicable, eater "crcurpt .. in /lie license nrnnb c) q ^' (n� ` _ Bus. Tel. Address:3�jerr,�brN�� V r � • `� (al a o�°1l3 Alt. Tel. No.: r1S OWNER'S INSURA`iCE; WAIVER: Vani aware that the Licensee doe n t have the liability insurance coverage normally required by law. By my signature below, I hereby valve this requirement. I am the (check onc) ❑ owner ❑ ow'ner's agent. Owncr/Agent p Signature Telephone No N PTR/1f1T TLE: S t y �. `° 2196 Date. . :0.:. �. NORTH - TOWN OF NORTH ANDOVER- R PERMIT FOR GAS INSTALLATIONS This certifies that •)_ ..! has permission for;g installation a in the buildin of .� .... �! (�! / !�- at . dt . C�Cf........ , North" Andover, Mass. Fee. Lic. C,%�i3 . --fd- , �f� GAS INSPECTOR WHITE: App scant — TTd Y Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) c NORTH ANDOVER Mass. Date 9 f� building Location 11� IW55 %0/� Permit # Owners Name_�Z� New Renovation Replacement p Plans Submitted 0 (Print or Type) Installing Company Name ANDOVER PLG. & HEATING CO._, Address 571-1/2 SO UNION ST. Check one: Certificate Corp. 2122 Partner. LAWRENCE, MA. 01843 [_J Firm/Co. Business Telephone: 508 685-8383 ly/ Name of Licensed Plumber or Gas Fitter GEORGE 1 AROSE— Insurancr' Coverage: ' Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q 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 coverages. y LO -7 Signature of owneriagent of property Owner Agent U _ i hereby certify that all of the details and I.dotmation 1 have submitted (or entered) in above application are true and accurate to the best oC my knowledge and that all plumbing work and Insalladons performed under' Permit issued fog this application will --be inscompiianoa with all peitl'aml provisions of the Massachusetts State Cas Croda and Qmapter 142 of the General laws. //// By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE:V-� �> PlumbPlumber erSignature of Licensed Master Plumber or Gasfit ter Journeyman -_ 99R� License Number NEMESES "WEEMEMIKE MEN MIENNIMM no ENIMMEMMIN IMEMEMEM MENEM N MMMMIMMIM� (Print or Type) Installing Company Name ANDOVER PLG. & HEATING CO._, Address 571-1/2 SO UNION ST. Check one: Certificate Corp. 2122 Partner. LAWRENCE, MA. 01843 [_J Firm/Co. Business Telephone: 508 685-8383 ly/ Name of Licensed Plumber or Gas Fitter GEORGE 1 AROSE— Insurancr' Coverage: ' Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Q 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 coverages. y LO -7 Signature of owneriagent of property Owner Agent U _ i hereby certify that all of the details and I.dotmation 1 have submitted (or entered) in above application are true and accurate to the best oC my knowledge and that all plumbing work and Insalladons performed under' Permit issued fog this application will --be inscompiianoa with all peitl'aml provisions of the Massachusetts State Cas Croda and Qmapter 142 of the General laws. //// By Title City/Town: APPROVED (OFFICE USE ONLY) TYPE LICENSE:V-� �> PlumbPlumber erSignature of Licensed Master Plumber or Gasfit ter Journeyman -_ 99R� License Number