HomeMy WebLinkAboutMiscellaneous - 255 FOREST STREET 4/30/2018 (2)N
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CLAIMS DEPT.
July 06, 2012
Commerce InsurancesM
The Commerce Insurance CcmuanysM
Citation Insurance Cemuany-
Members of The Commerce Group, Inc. -
11 Gore Road, Webster, Massachusetts 01570 (508) 949-1500
www.Commerceinsurance.com
BUILDING COMMISSIONER or
INSPECTOR OF BUILDINGS
TOWN/CITY HALL
NORTH ANDOVER MA 01845
Board of Health or
Board of Selectmen
Town/City Hall
RE: Our Insured: JEFFEREY A WDOW / ELIZABETH E WDOW
Property Address: 255 FOREST ST
Policy#: W06216
Date of Loss: 07/04/2012
File#: CACP11-WXHM60
Claim has been made involving loss, damage, or destruction of the above captioned
property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable.
If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate,
please direct it to my attention. Please reference the above captioned insured, location,
policy number, date of loss, and file number on any correspondence.
ESTHER O'NEILL Telephone: (508)949-1500 Ext: 15388
Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15388
On this date, I cause copies of this notice to be sent to the persons indicated above, at the
address above, by first class mail.
July 06, 2012
CcI11mUrc Ccmpanies .... COME GROW WITH us
CIC 254 (Rev. 4/95) MAEL M80
Date ..//..>.4 . .... .
1
3=a• ,,.o ,•tioL
p TOWN OF NORTH ANDD-
�' • - PERMIT FOR G STALLATION
i 0
9s_ • � v
This certifies that ,�.� `!l
..............
has permission for gas installation ....................
in the buildings of ... o.� ...............................
at . � . . ... !? ................... (, North Andover, Mass.
Fee.:?, .. Lic. No..�°�. ...... .
GIS INSPECTOR u
_ r
Check # O
6211
G
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
/V / L e 'Mass. Date
(p - 2007 Permit # 4 2_Z1
Building Location • )Co- 7e( --,n I— J
Owner's Tel # �. cc>c^)„ 4s 4
New 1:1 Renovation M Replacement n
Owner's Name DGIVO
Type of Occupency C�
Plan Submitted: Yes No
Installing Company Name Addario's Plumbing & Heating LLC. Check one : Certificate
Address 20 Cooper Street X Corporation 2720
Lynn, MA. 01905 Partnership
Business Telephone 339-440-8100 Firm/Co.
Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr.
Insurance Coverage :
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑x No ❑
If you have checked rte, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Ex 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 1:1 Agent
Signature of Owner or Owner's Agent
I hearby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application ' b in co with all p inent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title X Plumber
Cityrrown Gasfitter Signature of Licensed Plumber or Gas Fitter
Approved (OFFICE USE ONLY) X Master
Journeyman License Number 13106
•
Installing Company Name Addario's Plumbing & Heating LLC. Check one : Certificate
Address 20 Cooper Street X Corporation 2720
Lynn, MA. 01905 Partnership
Business Telephone 339-440-8100 Firm/Co.
Name of Licensed Plumber or Gas Fitter Steven J. Addario Jr.
Insurance Coverage :
I have a current liability policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑x No ❑
If you have checked rte, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Ex 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 1:1 Agent
Signature of Owner or Owner's Agent
I hearby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations performed under the permit issued for this application ' b in co with all p inent
provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By Type of License:
Title X Plumber
Cityrrown Gasfitter Signature of Licensed Plumber or Gas Fitter
Approved (OFFICE USE ONLY) X Master
Journeyman License Number 13106
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Location aTJ r r S
No. Date '6-7-03
HORTM
TOWN OF NORTH ANDOVER
41
Certificate Occupancy
$
4L
of
sACMUS
Building/Frame Permit Fee
$ 30
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
$ 3
�* Check #/ y 7 j
(19
Building Inspector
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........ ....'.......... Z::-:g'nz ........:.. ...........................
ti
has permission to perfo '- - - ^
` 1,
wiring in the building of r ;. / �-'�*`- ��'
..:......................................................................... .
at.:. �......... ,��....................... ................ .North Andover, Mass.
5 � a;3'? .sem/' r
Fee ..................... Lic. No. r
ELECTRICAL INSPECTOR
Check a /� v
4937
?;;�s
BOARD OF FIRE
APPLICATION
All work to be Dert
(Please Print in ink or type all information)
Town of North Andover
6� ss�G�us��rs
r %�uefte sG�tt j
ON REGULATIONS 527 CMR 12:00
vu+udi Use
Permit No. q3
Occupancy & Fee Che(
(PERMIT TO PERFORM ELECTRICAL WORK
accordance with the Massachusetts Electrical Code 527 CMR 12:00
The undersigned applies for a permit to perform the electrical work described below.
Location (Street & Number
Owner or TenantiP�Ci
Owner's Address S A '` e—
Date 1-7-0-3
To the Inspector of Wires:
Is this permit in conjunction with a building permit Yes 0 No 0 (Check Appropriate Box)
Purpose of Building CS % C`( Vl (2 Utility Authorization No.
Existing Service t6}O Amps O Voits Overhead Undgmd 0 No. of Met(
New Service Amps Voits Overhead 0 Undgmd 0 No. of Meti
Number of Feeders and Ampacity?6V C l
Location and Nature of Proposed Electrical Work
--
Total
No. of Lighting Outlets
No. of Hot fuse
No. of Transformers KVA
�j
Above 0
In 0
No. of Lighting Fudures
Swimmi Pool gmd 0
gmd 0
Generators KVA
No. of Emergency Lighting
No. of Receptacles Outlets
No. of Oil Burners
Ba Units
No. of Switch Outlets
No of Gas Burners
FIRE ALARMS No. of Zone _
No. of Detection and
Total
No. of Ran
No of Air Cond
Tons
Initiating Devices _
Heat Total Total
No. of Diposal
No. Pumps
Tons
KIN
No. of Sounding Devices
NoJ of Self Contained
No. of Dishwashers
S Area Heating
KW
Detection/Sounding Devices _
0 Municipal 0 Other
No. of Dryers
Heating Devices
KW
Local Connection
No. of
No. of
Low Voltage
No. of Water Heaters KW
Signs
Bailases
Wiring
No. Hydro Massage Tuds
No. of Motors
Total HP
INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws
I have a current Liability Insurance Policy includimpleted Operations Coverage or its substantial equivaau
NOhav valid proof of same to the OffiYES NO - if you have checked YES please indicate theerage by checking the appropriate box.
INSURANCE -D BOND = OTHER - (Plea pecify)
(Expiration Date)
Estimated Value of. Electrical Work$
Work to Start (—G-- _�, Inspection Date Resquested �- �� Rough Final
Signed under the PpPattieS of perjury: _ -
FIRM NAME J t T ,ttCM LIC. NO. ���J A .
NO. U F
tq Bus. Tel N6! C3 -r S ^ 'YO / " (VU j
Address / 6S �G y K/nFX°�YAlt Tel. No. - ^3 Z.
OWNER'S INSURANCE WAIVER: 1 am aware tha the Licenses does not have the insurance coverage or its substantial equivalent as required by Mass
General Laws. And that my signature on this permit application waives this requirement. Owner Agent (Please Check one)
Telephone No. PERMIT FEE
(Signature of Owner or Agent)
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
OR DEMOLISH A ONE OR TWO FAMILY
BUILDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/Inspector of Buildings Date
I SECTION 1- SITE INFORMATION I
1.1 Property Address:
5 �vres
1.2 Assessors Map and Parcel
- o( A
Map Number
Number:
17 9
Parcel Number
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
Required
Provided
1.7 Water Supply M.G.L.C.40. 54)
Public 0 Private ❑
1.5. Flood Zone Information:
Zone Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record
1/'3C.LKPIVI Lo CID ('6
Name Pnnt)Address for Service
/��
arc �ftl �C�
Signature t elephone C/r
/-q7S- 6�Z- G' //R
2.2 Owner of Record:
Name Print
Al
pow''
2SS IcalTEST S%
Address for Service:
SEC'CION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
W/ -Ifs- 1¢ c S OAI
Licensed Construction Supervisor:
2 A%A LSI IVE LA l�i�C/ycE /Mass
Address
Signature Telephone
3.2 Reg�tered Home Improvement Contractor
DLCKgaw
Compai� Name
Address i I n A
Not Applicable ❑
p -S-a
License Number
?/.;-, 3
Expiration Date
Not Applicable ❑
03 s y
Registration Number
7610
Expiration Date
i
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SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Description of Proposed Work (check all anDlicable
New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ 1 Alterations(s) ❑ 1 Addition (0 )'
Accessory Bldg. ❑ 1 Demolition (01 Other ❑ Specify
Brief Description of Proposed Work:
I SECTION 6 - ESTIMATED CONSTRUCTION COSTS I
Item
Estimated Cost (Dollar) to be
Completed by permit applicant
OFFICIAL USE ONLY
1. Building
f/
(a) Building Permit Fee
Multi Tier
2 Electrical
(b) Estimated Total Cost of
Construction
33 f>" E_
3 Plumbing
Building Permit fee (a) x (b)
3 ..�
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR \C—ONTRACTOnR APPLIES FOR BUILDING PIERMIT I, �� p (� eu �Co IN �Wl I '� �) r�bl� 1 , as Owner/Authorized Agent of subject property
fereb'
a orize to act on
el 1 , i a matters r lative to work authorized by this building permit applicatio .
S r u of Own i.�X�Prnn�Dte
S TI N 7b OWNER/AUTHORIZED AGENT DECLARATION
� (� lj�(''' u( e) �� �(;( 1>� uid� ,as Owner/Authorized Agent of subject y
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
AA fin r� � . _ I
of Owner/
Date
O. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIIvMERS 1 ST 2ND 3 RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
I MIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
8
i
PLS,^ C
FORM U - LOT RELEASE FORM1._03
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 // T, C Sp TAc�'sos�
LOCATION: Assessor's Map Number
SUBDIVISION
STREET_
****�`*********************"*******'OFFICIAL USE
TOWN AGENTS:
CONSERVATION ADMIN TRATOR
COMMENTS We.41u4,1s exp N., too
PHONE
PARCEL
LOT (S)
ST. NUMBER
DATE APPROVED
DATE REJECTED
'
wief� 6r �w�w�c �k w�4N ielictiJ'c 0.tjllnG
� - V
TOWN PLANNER
COMMENTS
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED,
,r
SEPTIC INSPECTOR -HEAL DATE APPROVED
DATE -_REJECTED-,
COMMENTS
S
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9\97 jm
DATE
MORTGAGE PLOT PLAN
EK SURVEY
17. ROYAL STREET, LAWRENCE, MA. 01841
TELEPHONE 508---975-1413
MORTGAGOR
ADDRESS OF PRINCIPLE BUILDING
SCALE I" = 50'
DEED REF. BK.. «-. — PG. z�
PLAN REF.40s`" -�
DATE OF INSPECTION 17-1-1-L
t
d5 O�
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Of
AL8ET; rn
TRUDEL
DWeCc4�wC> tS� q�� F s No. 36EG9
tt i1f` • �'""
►z554�
OTE; THIS MORTGAGE INSPECTION WAS PREPARED
'ECIFICALLY FOR MORTGAGE PURPOSES AND IS NOT TO
REUEC UPON AS A SURVEY. EK SURVEY ACCEPTS
0 RESPONSIBILITY FOR DAMAGES TO ANYONE OTHER THAN
iE SAID MIRTGACEE AND ITS ASSIGNS IN CONNECTION WITH
'S PROPOSE` MORTGAGE FINANCINO TO SAID MORTGAGOR.
%ER11FICA1i;2N T0: kWBQ4 VVL-,�IAA_
HIS CERTIFICATION IS BASED ON THE LOCATION OF SURVEY MARKERS
F OTHERS, AND DOES NOT REPRESENT A PROP ERTY SURVEY, THEREFORE
OFFSETS SHOWN ARE NOT TO BE USES FOR THE ESTABUSHMENT O!=
PROPERTY LINES.
I FURTHER STATE THAT IN MY PROFESSIONAL.
OPINION THE PRINCIPLE STRUCTURE/S AND ACCESSORY
OUTBUILDINGS C K ��'��"��'
WITH THE SETBACK REQUIREMENTS OF THE LOCAL
ZONING ORDINANCES, AND THAT NO ENCHROACHMENTS
OF MAJOR IMPROVEMENTS EITHER WAY ACROSS
PROPERTY UNES EXCEPT AS SHOWN,
ALSO:
®1. PROPERTY IS NOT IN THE 100 YR. FLOOD HAZARD AREA
02. PROPERTY 1S IN A FLOOD HAZARD AREA
jJ 3, INFORMATION IS ISUFFICIENT TO DETERMINE FLOOD HAZARD.
FLOOD HAZARD DETERMINATION FROM THE LATEST FEDERAL FLOOD
INSURANCE RATE MAP PANED 8!VC>4 CaCOC)q C
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S.150A.
The debris will be disposed of in:
N,
(Location of Facility)
�/72/Z 4 L �
AignatGre of L -
.
Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through. the Office of the Building Inspector
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JACKSON BUILDING AND REMODELING
2 RITA LN. 7 FARRWOOD DR.
LAWRENCE, MA 01843 BRADFORD, MA 01835
9''f g (5®13) 683-6619 (508) 521-5193
MA. LIC. # 050976
PROPOSAL
PROPOSAL SUBMITTED TO
PHONE
DATE
6/23./03
STREET
JOB NAME
CITY, STATE AND ZIP CODE
North Andover TKA
JOB LOCATION
ARCHITECT
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for.
Build 12' x 1 '
Permit to be obtained..
Remove Pres-ent deck
Excavate .to code d. `
s. a "
s rr rr
-
Build vressure ".te '* x T2"-
Fzame u
Frame
Install lead flashing
Install 2.5 ear asphalt
Install "TREV
Build..j2ressure
Enclose under porch
Payment to be made
1st - $5,000
2nd - 9,000 when.roofed
3rd - 4,410 when above
We Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of:
dollars
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed In a substantial workmanlike
manner according to specifications submitted per standard practices. Any alteration or deviation from
above specifications Involving extra costs will be executed only upon written orders, and will become
an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or
delays beyond our control Owner to carry fire, tornado and other necessary Insurance.
Authorized
Signature
Note: This proposal may be
withdrawn by us if not accepted within days.
Acceptance of Proposal- The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized to do.
the work as specified. Payment will be made as outlined above. Signatur
Date of Acceptance: I Signatur
If
634
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Name Please Print
f T� KSo,v—,TcksaN 2) req � J?,Clv6;.
V v
Location:
City Phone #
I am a homeowner performing all work myself.
I am a sole proprietor and have no one working in any capacity
I am an employer providing workers' compensation for my employees working on this job.
Company name:
Address
City: Phone #
Insurance. Co. Policv #
Company name: ,
Address
City: Phone #-
Insurance Co. Policv #
Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of.a free tip
and/or one years' imprisonment_as_vel-as_caal.penalbeslnSheimnnfa�7DPYiK)RK9RDFR-and arm -d 1DA OD -a to $1,50U.00
understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for i l
coverage verification.
l do hereby cerW under the pains pndpena/ties ofpe.7wy that the Wwnation provided above is true and correct.
Print name Ni/%/i S T CAS aly Pie.#
Official use only do not write in this area to be completed by city or town offiaar
City or Town PermM iccensing
D Building Dept
E]Check Y immediate response is required .0 Licensing Board
E] Selectman's Office
Contact person: Phone #. E] Health Department
Ei Other
TOWN OF NORTH ANDOVER
PUBLIC HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
July 9, 2003
Phil Jackson
Jackson Bldg & Remodeling
2 Rita Lane
Lawrence, MA
Re: Application for 3 -season room addition
Dear Mr. Jackson:
NORTh 9
OL
it
�SSaCHU`�E�
Telephone (978) 688-9540
FAX (978) 688-9542
Your application for a building permit at 255 Forest Street, North Andover has been reviewed by the Health
Department. The application was denied on July 9, 2003 for the following reasons:
1. X Missing information.
A scaled plot plan no smaller than 1"= 40' must be submitted showing the dwelling, the location of the
existing septic system and the private well, and the proposed addition.
2. X Title 5 inspection of septic system. (Please note that this is one of the easiest ways to locate your septic
system).
3. Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition all rooms
b. ed slt1�wit ll�tit P�y Vit[ .. P131?se imp e
If #2 is checked:
a.
e er,r,xsyanerat,n.ttrti
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
Homeowner
File
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MM—Z—WW--
255 FOREST STREET
NOTE:
EXISTING SEPTIC SYSTEM LOCATION DETERMINED IN
THE FIELD BY BENJAMIN C. OSGOOD JR, CERTIFIED
TITLE 5 INSPECTOR.
758 'BY' S. B. BY.CHECKED BCO jr
DECK
ROOM C io p c H J
SEPTIC SYSTEM LOCATION PLAN
255 FOREST STREET
NORTH ANDOVER, MASSACHUSETTS
PREPARED FOR PHILLIP JACKSON
2 RITA LANE, LAWRENCE, MA
SCALE: 1" = 20' DATE: JULY 25, 2003
NEW ENGLAND ENGINEERING SERVICES INC.,
60 BEECHWOOD DRIVE
lk NORTH ANDOVER, MASSACHUSETTS
(978) 686-1768
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN(3
(Print or Type)
l NORTH ANDOVER Mass. Date s��
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a -A���§uilding Location L Permit #
I . Owners Name Gz/ Z) G
New K Renovation [] Replacement Plans Submitted _
FIXTURES
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(Print or Type)
Installing Company Name G(/��,tJ,ll✓�Gc/�//✓5��/�/
Address Sal SZO
Check one: Certificate
(� Corp.
Partner.
Firm/Co.
Business Telephone:�J
5 = O ?- 7 -
Name of Licensed Plumber
or Gas Fitter
cX It -/E/? SA
crt A- )
Insurance Coverage: Indicate the type of insurance coverage
by checking the
appropriate box:
Liability insurance policy
M 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.
111
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iiii�iiiii�iii�iii�iiiiii
(Print or Type)
Installing Company Name G(/��,tJ,ll✓�Gc/�//✓5��/�/
Address Sal SZO
Check one: Certificate
(� Corp.
Partner.
Firm/Co.
Business Telephone:�J
5 = O ?- 7 -
Name of Licensed Plumber
or Gas Fitter
cX It -/E/? SA
crt A- )
Insurance Coverage: Indicate the type of insurance coverage
by checking the
appropriate box:
Liability insurance policy
M 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.
Signature of owner/agent of property Owner F] Agent El
I hereby certify that allot the details and information I have submitted (or entered) in above appfceation are true and accurate to the best of my
knowledge and that all plumbing work and hutallations performed under Permit issued for this application will -be -In compliance with ad pertinent
provisions of the Massachusetts State Gas Code and Chapter 14: of the General Dews.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY} -----
TYPE LICENSE:
Plumber'�2�r
Gasf itter ignature of Licensed
Master _. Plumber or Gasfitter
Journeyman 9� 64
License Number
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2023
Date. .
'40RT" TOWN OF NORTHog ANDOVER
PERMIT FOR GAS INSTALLATION,
o
This certifies that
has permission for gas installat.
0
in the buildings of ... ....................... w
at . =)SS... d..:... North Andover, Mass.
Fee. LiNo ..........................
46- GAS INSPECTOR
WHITE: Applicant Building Dept. PINK: Treasurer GOLD: File