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HomeMy WebLinkAboutMiscellaneous - 26 MILLPOND 4/30/2018Town of North Andover D.B.A. — Zoning Compliance Form 978-688-9545 This form must be reviewed with the Inspector of Buildings. Office Hours are Monday -Friday 8-10 am, and 1-2 pm Monday -Thursday. Pg- L-eb"L& Applicant Name: 2:a t O �E P J Q n k t S Name of Business: K tF, U A-.155 6L C -U ct S � S : :2—& kXLLl.., vN) Map O C( j Lot -0 O ak- l0 District Phone: 1-0& R5 -6Z 87- Email my b 5 a. u ^-A % ( Z °t t L . L © ,a -t Nature of Business:b ��.� (:� Ci rC1� ►l.t.ivLG� Do you own this property? Yes z No If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No Will you have any employees? Yes fo No Will you have any major deliveries? Yes No Description of Business Activity (Must be Completed) � e c P ri�� r Vc Signature of Applicant_",C_ - ��1,C L\�—(,C For Signage Refer to North Andover Zoning Bylaw Section 6 O nO q cx«ww < • 'ti L 1• Town of North Andover D.B.A. — Zoning Compliance Form 978-688-9545 This form must be reviewed with the Inspector of Buildings. Office Hours are Monday -Friday 8-10 am, and 1-2 pm Monday -Thursday. Pg- L-eb"L& Applicant Name: 2:a t O �E P J Q n k t S Name of Business: K tF, U A-.155 6L C -U ct S � S : :2—& kXLLl.., vN) Map O C( j Lot -0 O ak- l0 District Phone: 1-0& R5 -6Z 87- Email my b 5 a. u ^-A % ( Z °t t L . L © ,a -t Nature of Business:b ��.� (:� Ci rC1� ►l.t.ivLG� Do you own this property? Yes z No If no, written permission is required from your landlord. Will you have clients coming to this property? Yes No Will you have any employees? Yes fo No Will you have any major deliveries? Yes No Description of Business Activity (Must be Completed) � e c P ri�� r Vc Signature of Applicant_",C_ - ��1,C L\�—(,C For Signage Refer to North Andover Zoning Bylaw Section 6 7767 Date. .7. —. 0. -. �. � ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... �;- ✓L L.. 4 : ... uj��')ac ............. has permission for gas installation W !4-F:cr' in the buildings of .... � c�? .6 at ... . ....... I North Andover, Mass. Fee*.30 vq . Lic. No. .... stacAiL, ........ r GASINSPECTOR Check# 5 —�-6 CIYTI IGCC MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING a Ci /Town AA ty •Vl�� MA. Date: /jot Permit# Building Location: cq POwners Named /G Type of Occupancy: Commercial ❑ Educational E] Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ��--Plans Submitted: Yes ❑ No ❑ CIYTI IGCC 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 have -checked Yes, please indica a type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent ❑ By checking this box ❑; 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and ..WOE V —Y n11UW UUt; a1Ju Lna[ au piumomg work ano mstauatlons perrormed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: e-PittFnber Title ❑ Gas Fitter i ature censed Plumber/Gas Fitter ❑ Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY 0 LP Installer W co Z w Lu F- Q V)Q N 2 Cd :3 m= ujW O� uJ U 0 1--V)O F w Z H g (9 Z5 J W Lu W O WW' W W W m �0 Q a 1— a 0 Q F W X W> co V Z W Z 9 W 0) O Q W =� lX � 0 W Z O J 1— H O Z J U' u. N = W H W W v o o u- 0 0 z z g 0 Da W F>>> o SUB BSMT. BASEMENT 1 FLOOR --i 'FLOOR 3 FLOOR --4 'FLOOR 5 FLOOR 6 1H FLOOR 7 FLOOR -i 'FLOOR e , Check One Only Certificate # Installing Company Name: lG � (( � Address �� �, ) /iL� S/� �Ci't4Ln: �.. C State <% ElCorporation ❑ Partnership Business a0 Fax: t.�--qa sy Name of Li Plumber/Gas Fitter: 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 have -checked Yes, please indica a type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent ❑ By checking this box ❑; 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and ..WOE V —Y n11UW UUt; a1Ju Lna[ au piumomg work ano mstauatlons perrormed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: e-PittFnber Title ❑ Gas Fitter i ature censed Plumber/Gas Fitter ❑ Master City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY 0 LP Installer Gonnnnotvvu€Ai.=rl of MASs`rHusE rb %' ve °• • a IN .P LUMBERS AND GASFITTERS LICEIISSD AS eo MAS NERTo LUMBER ,+ ERIC .,J WHITE 21 E.DUNSTABLE RD NH 03060-586 }± NAS,HUA. CONTROL# QQQ823�9"�, IMPORTANT If this' license"is lost or destroyed, notify° Division of Professional Licensure, 1000 Washington St,, ! r 7th Floor, Boston, MA 02118. If our name or address shown is changed, notify 1 i Y g of correct name or address to!ii� re proper mailing your next 1` Renewal Application. Always refer to your license: number. This license is subject to the provisions. of the: General Laws as amended. It is a personal privilege, and must not be loaned or assigned to any other person. Keep this license on your tperson or posted as required by law. F WARNING THIS DOCUMENT HAS • .., _ _:ENHANCED S.ivGk!:t'=.[. a+-,,...---.,�.•_ r ` 13 7 4 Date .... /./`*­zA % .. ... + TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING a 0 This certifies that ....... ................................. has permission to perform .... ......... f'oo.E? C..01. nP . wiring in the building of .......I...............A ........................................................ o at ...... ................ .North Andover, Massi. .......... Fee.... Lic. No..?`.. ........................................................ ELECTRICAL INSPECTOR a tt (S j WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Office Use ONy uE L:L:lill� If�� Permit No. lT1 11t Lhr Ocalpattcy CAecked d Fee .: J - (leave ktMrtl)- BOARD OF FIRE PREYE.MCH RMULAIIONS 527 CUR 1200 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 'WORK • All work to be performed in ac=rrt Cace-with the Massacnusetts Electrical Cade, 527 C. (PLEASE PRINT IN. INK OR TYPE ALL INFORMATION) Date i�ec 12:00 f'i99? (M* or Town of I'IORTH eNnt7�R To the Inspector of Wres: The udersigned applies for a permit to perform the electrical work described below. Location (Street & Numb r) Owner or Tenant �Ctl' dnt� g Cwner's Address Is :his permit in coniunc:ion with a cuiicirg der^..iC Yes _ No (Check Appropriate Box) P::rccse cf Suiidina Utility Autttcrizatian No. Sxistirg Sarlice Amos _1 vcits Cverread '_ Uncgrna ❑ No. of Meters New .Service Amps Cvernead r Uncgmd !_ Na. at Meters Number of Feeders and Ampacity Warr) L^1 ,�+ '/ C r r�i iNCfK Wp 1 � / 17•I 1 t/ Location and Nature of Proposed Ele +ii'eee 1 � Tatal Na. at L:gnnng Cut:ets ' Na. - acs ! No. cr'ransformers �A No. of '_:gr.ttng = xtures S°' r" T ng 1rnc. _ _ ^c. _ Generators tCVA No. at crrergency Lignttng v.. �: ce,.a.,.�.-•o ^cartes No. oi• Cit Surners i Barer -4 Units. No. at Switch Cutlets No. of Ranges NO. at -1--isccsais No. :it Cisnwasners Na. at orvers Nc. or water-leaters No. Hydro Massage Tugs No. or Sas 3urners .otai No. a: Ad =ZrC. =n5 -eat otat otai No. ::r _- =s ..-ars 'C:J ­ea::ng Cevices <%f FIRE AL.ksmS No. of Zones No. ct Cetection and Inriaung Devices I No, cr Sounaing Cavices i No. ::v Contained Cetec::cniSauncing Cevices Munic:eai Cther __cal _ Cannec::on '_ No. ar No. cr I Law .0 Cage KW i Signs-a!tas.s Wirtr.c iNo_ ct %tctcrscrai '+P 1NSURANC= CCV E?AG Pursuant :o :ne rec_:re:ner.:s cr massacnusers yenerat Laws I nave a current l aciiity Insurance Polic/inc_C:r.q Ca.._. -t o ^n ed Cceraes Caverage or :ts suds:antial ecuivaient. YES _ NC nave suemirtea valid proof of same Ctfics. Y=S _ NC = t :cu ,nave cnecxec YES. crease incics(e :he .type at coverage ::V cnecxing the at:CMOrtats pox. _ INSURANC= = SCNO = OTHER _ ;?'ease Scec:ry) (ExDtration Oatei Esttmatea Value of E?ectrtcal work S Final tnsaec-cn Ca:a '.acues:ec: Raugn warx to Start _ Signea under •he Penaties nof p g ry- J� %l95 FIRM NAME ,ito e � 6 A�l � �Cl` IC UC. NO. A 5 Slc,-att:re UC. NO. Licensee 97�-J 1-733�— s AddresEus. :el. No. CWNEa'S INSURANCS WAIVER: 1 am aware mat : e L:cer.see -cea rot -Iave :rte insurance coverage a its suostantial eQuivalent as -e cwrea 7y Massaenuseas General Laws. aria that iy s grature en Ls :errrit acpucanori waives this naawrement Owner Agent (Please cheGGt oriel `uj --eieorac. ne No. PERMIT FS ts;gnature at Owner of Agentl 1-6565 a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 00 P MBING Pant or Typal ' Maas. 19PertMt BWd�+s tarallon (✓ M. (.t . eOti1> ,,., owner's Nameo?� MAS �002-T,,,Ai, V�Q,t� d lel Typ! Cf Oorx tCl/��! t DE U T� r1.�t New 0 RenovadOn 0 FDCTURES Plans SIaDrnl<tetl: Yes 0 No O Wafts Taisphars,,,,_ Nanta d Liewm d PkMw I l how & cuetsntyabtlp► Maof PaNC!► or � mbl CE COVE:tAOE: rdd Nr msrts go m**wnsnts d MOL Ch. 142 w aY 9 you haw ehsdmdn& ~'- p _ -, s itis b" sennas by cheoWN the spprdPdA* boot A llab W Mrusanes PWW Oaeot t" of bdo No 0 Bard 0 OWWM,S p" IR"M WAr4M I Wn aware that the poonsom doll nct hw4L !hs kwxu of cmwW mWW by Chaplet 142 at um Maes. eowd Laws. and Md req/ on 00 Pw"* Nw wAIV" Oft feauvwrAft Chedt ono: owner '0 AqW 0 i 1wMy arlpl► tial all d tln dnMdt and iMane�tdien t boys 'wbnrigsd for wdwtrd) in abate wllm =moWA �la " VW so a� o a a lir w° W"tlta o erWW" MAFAW I = fA Ty" of UWAL Maw � % .Joanerrwr D n umm 1a .. • Wafts Taisphars,,,,_ Nanta d Liewm d PkMw I l how & cuetsntyabtlp► Maof PaNC!► or � mbl CE COVE:tAOE: rdd Nr msrts go m**wnsnts d MOL Ch. 142 w aY 9 you haw ehsdmdn& ~'- p _ -, s itis b" sennas by cheoWN the spprdPdA* boot A llab W Mrusanes PWW Oaeot t" of bdo No 0 Bard 0 OWWM,S p" IR"M WAr4M I Wn aware that the poonsom doll nct hw4L !hs kwxu of cmwW mWW by Chaplet 142 at um Maes. eowd Laws. and Md req/ on 00 Pw"* Nw wAIV" Oft feauvwrAft Chedt ono: owner '0 AqW 0 i 1wMy arlpl► tial all d tln dnMdt and iMane�tdien t boys 'wbnrigsd for wdwtrd) in abate wllm =moWA �la " VW so a� o a a lir w° W"tlta o erWW" MAFAW I = fA Ty" of UWAL Maw � % .Joanerrwr D n umm I • I 2 0 N6 0 • I • I ` MASSACHUSETTS UHIFORM APPLtCATt0t4-FOR PE -MIT;­TO:00'PLU (Type or Print) NORTH ANDOVER ,Massa : i1:<.. •. ' ' Date:, Building Location -'Z; t rn 1414 00 +✓ fl`N Permit �, Owners Name cS' -77;1 rh /9-S New D Renovation j] ' Replacement [� Plans Submitted FIXTURES %w z z Im;/► z x < p / h (Print or Type) Installing Company Name Address Check one: Certificate _s -[D Corp. -.• Partner. Firm/Co. Business Telephone/ p Name of Licensed Plumber:7 e __ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ['M Other type ,of indemnity 0 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 ownerlagent of property Owner ❑ AgeneN 0 j I beKbr artily tial all of Use details and information t have subinittcd (of cnlc1cd) in above applicllion ate Isut attdnlale 10 Vte bell r Mr —• - knowledge and that all plumbing work and installations locrfnrmcd undo renuil ksucd (or this application will be M wish so PW/lacµ pqr ,o vision of the Massadtusclll State Plumbing Code and aLaptct 142 a( the Qnef;) awt By i iTitle City/Town: z oor?nvrn 7oFFtrF usE oNt.r, Signature ofLicensed Plwnber Tv a of Plumbing License /Y License Number ❑ Master �Journeyaap bc 0393 - . Cr O v x < In 2 a n .. W cc W Q3 cc W cc Is a T -O o)VccX W O) O 3 Ka 1w) O O CC 03 m s Y) 0 Q cc 0 cc O jr, O w KW¢ x< r- O z Q O 10 .I < ic.c IL X W ]L J Q o .1 = H to IL O a < '17c o Q SUB-,BSMT. BASEMENT IST FLOOR 2NOFLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR ±E 8TH FLOORI (Print or Type) Installing Company Name Address Check one: Certificate _s -[D Corp. -.• Partner. Firm/Co. Business Telephone/ p Name of Licensed Plumber:7 e __ Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ['M Other type ,of indemnity 0 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 ownerlagent of property Owner ❑ AgeneN 0 j I beKbr artily tial all of Use details and information t have subinittcd (of cnlc1cd) in above applicllion ate Isut attdnlale 10 Vte bell r Mr —• - knowledge and that all plumbing work and installations locrfnrmcd undo renuil ksucd (or this application will be M wish so PW/lacµ pqr ,o vision of the Massadtusclll State Plumbing Code and aLaptct 142 a( the Qnef;) awt By i iTitle City/Town: z oor?nvrn 7oFFtrF usE oNt.r, Signature ofLicensed Plwnber Tv a of Plumbing License /Y License Number ❑ Master �Journeyaap ,00l, 7,�� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF17TING (Print or Type) NO, ANDOVER, MA Mass. Date -19 Permit Bullding Location � MILLPOND Owner's Name ®qAg�a , NO.ANDOVER,MA New ® Renovation ❑ Type of Occupancy. RES Replacement ❑ . Plans Submitted: Yes[] No ❑ Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certtflcate 7 Address 91 BELMONT STREET — Q� Corporation N0. ANDOVER, MA . 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN C=.LLAHAN INSURANCE COVERAGE: I have a current Ilabllity Insurance policy or tts substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes R3 No O If you have checked Les, please Indlcate the type coverage by checking the appropriate box. A Ilablllty Insurance polity 0 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 watves this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted. (or enterec) :n ove appricallon are true and accurate to the best of my kricydedge and that all plumbing work and Inslallauons performed under the perm,,, sued for this appllcau will b In p(lance with all perdnent pravisiona of the MassacthuselLs Slate Gas Code and C:lapter 142 of the neral hw ey Tj4u f ucense: f mbe, Snatur o c nse umbo or Title srlterUc _nse Number M— 3 4 4 0 urneyman M f'fICT/fryT l rC` C V1 N v7 U -_ 1� I cc V] ¢ w I V71 O U Y- _ - n w J cc w 0 O O = 0 o H O1 W U w ` Vf CC ul O > O h" w O w w NO c w lA I < < w O e v w = w = < c p < C I a c V 0 C > — a 0 l SUB—BSMT, I I I I I I I I I I I BASEMENT I I J 1 ST FLOOR I I I I I I I I ( I I I I I 2ND FLOOR 3R0 FLOOR 4TH FLOOR I I I I I I I I I I I STH FLOOR CTH FLOOR 7TH FLOOR a T H FLOOR I I I I I I I I I I Installing Company Name CALLAHAN AIR CONDITIONING Check one: Certtflcate 7 Address 91 BELMONT STREET — Q� Corporation N0. ANDOVER, MA . 01845 ❑ Partnership Business Telephone 508-689-9233 ❑ Firm/Co. Name of Ucensed Plumber or Gas Fitter JOSEPH KEVIN C=.LLAHAN INSURANCE COVERAGE: I have a current Ilabllity Insurance policy or tts substantial equivalent which meets the requirements of MGL Ch. 142- Yes 42Yes R3 No O If you have checked Les, please Indlcate the type coverage by checking the appropriate box. A Ilablllty Insurance polity 0 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 watves this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owners Agent I hereby certify that all of the details and information I have submitted. (or enterec) :n ove appricallon are true and accurate to the best of my kricydedge and that all plumbing work and Inslallauons performed under the perm,,, sued for this appllcau will b In p(lance with all perdnent pravisiona of the MassacthuselLs Slate Gas Code and C:lapter 142 of the neral hw ey Tj4u f ucense: f mbe, Snatur o c nse umbo or Title srlterUc _nse Number M— 3 4 4 0 urneyman M f'fICT/fryT l rC` C Af - M4 Date. .J9G. I "ORTM TOWN OF .NORTH ANDOVER tN PERMIT FOR GAS INSTALLATION 9 y�SACuuSEtS This certifies that L . ............ .. (. .. , ... , , . g. has permission for gas installation .. F ` !'. ` A .''. ... . in the buildings of .... .�4 (�.?................... . at ....a.b ...� [1.4 . Iw: � ........ N Andover, Mad. Fee. .1 ; Lic. No., 3.%� .... I.S- . IN SPECTOR WHITE: Applicant CANARY: Building Dept: PINK: Treasurer GOLD: Fry c � A Date 359 F, c � A TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that haspermission to perform ... 1 .kl........................... plumbing in the buildings of S. .................. at .... ft.l.�. l O..!-�.. , N h Andover, Mass. Fee .. ��; .'.. Lic. No"/ L�� � ,rt' ...... � . ��.:.... . LUMBING INSPECTOR q7 n 1 1� n p n ;± "MITE: Applicant CURRYIu7ding Dept. PINK: Treasurer Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that haspermission to perform ... 1 .kl........................... plumbing in the buildings of S. .................. at .... ft.l.�. l O..!-�.. , N h Andover, Mass. Fee .. ��; .'.. Lic. No"/ L�� � ,rt' ...... � . ��.:.... . LUMBING INSPECTOR q7 n 1 1� n p n ;± "MITE: Applicant CURRYIu7ding Dept. PINK: Treasurer Aw .J* Date .'L-(. -. 30 --0 V. - . . . . . . . . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that nr� Y. ................ has permission to perform ... P.,? LA�- ............ plumbing in the buildinsof V, .. .............................. at .......... U, k/k I � j ............. .............. North Andover, Mass. Fee. 3Q .... Lic. No. PLUMBING IN �PEICTOR Check # 6003 MASSACHUSETTS UNIFORM N FOR PERMIT TO DO PLUMBIN( (Type or print) NORTH ANDOVER, MASSACHUSETTS n N^ ( Date 747 7 Building Location pS /' 1 ! 1 •� ,110,\ Owners Name P12&17Permit # Amount Type of Occupancy New Renovation E] Replacement Plans Submitted Yes 0 No ❑ q .,FIXTURES F rr nd VA I E. W H � O A w SLRMW S4EVENr lSl� Plait j 2NII FIDOR 3Id2)HIDCit 4M )HIDM 5M H -OM 6M HDM 7M BLOM SII3FIDOR (Print or type) �r , /�j Check one: Certificate Installing Company Name �� %� V v C� Corp. Address �� C�� Partner. Business Telephone Firm/CO. ;A 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 ❑ 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�ssued for thi application will b compliance with all pertinent provisions of the Massachusetts State Plumbing Code and `hapter 14 he General Laws BY1gna ure ot LicenseariumDer Type of Plumbing License Title City/Town License TNumDer Master El Journeyman APPROVED (OFFICE USE ONLY. ` Date... k RT 6. . o? °` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 9q - This certifies that.................. has permission for gas installation ............ . in the buildings of rA. at .5R G. ( l PUN pQ.....................North An over, Mass. Fee.. 3 �... Lic. No. j . b � L5.. .. S'.) y (.3-7 -) GAS INSPECTOR Check # 4726 .4 MASSACHUSETTS UNIFORM APPLICATON (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations 01 1 PERMIT TO DO GAS FPI'1NG Date Permit # Amount $ c3 6) s Name � l f New ❑ Renovation ❑ R place Hent Plans Submitted ❑ W r x U 94 C6 W W a O OU M H x F x z a" a E"' z z o F-4 w Q °" a > Q an C4 z PQ U W W W OH A F 9 CW7 H z F z x W W O O w H U .4 z (Wx¢� a z Rte'. O O W O W H U 94 A C. F O SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND. F L O O R 3 R D. F L O O R 4 T H. FLOOR 5 T H. F L O O R 6TH. FLOOR 7TH. F L O O R STH. FLOOR (Print or type)�/� /� (`j y� Check one: Certificate Installing Company Name /GYM I ���� /� V oC� ❑ Corp. Address �}�/�ya�� �❑ Partner. Business Telephone ❑ Firm/Co. r Name of Licensed Plumber or Gas Fitter Q-2> 17— INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked Vis, please indicate the type coverage by checking the appropriate box. Liability insurance policy q Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner p Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true best of my knowledge and that all plumbing work and installations erformed under Permit Issued for this applii compliance with all pertinent provisions of the Massachusetts Ste Gac Cnde and C1� r 142 � the �ienero By: Title City/Town APPROVED (OFFICE USE ONLY) mature of Licensed Plumber Or Gas F ❑ Plumber �= ® Gas Fitter license Number ❑ Master Journeyman