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Home My WebLink AboutMiscellaneous - 27 SAMUEL WAY 4/30/2018w oil 1�1 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 384 (12/8/08) Date: July 15,2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 27 Samuel Way MAY BE OCCUPIED AS Sinale Family Dwelline IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Edgewood Retirement Community 575 Osgood Street North Andover MA 0 1845 Buildini Inspector (A m m m m m m m Es, cop) Cl) = - 0 CD C'3 ch CL co) CD 0 CD CL cr =r "C CD 4 CD 0 CD w CD CD ca CD ca 10 CD n CD .CD 0 Q C/) C/) n 0 C/) C� 1.21... 0 0 z C/) cn co: Z�) r\ 0C cz z =r ccl S. co CD CL CA CO) C4) 0 cr =t CL 0 co cc — a C-) ce 0 CL'C-) CD =r -C ce qtw EL CL CA CD ca -cc- cl CD so CD Co OL CD CD 72 cro CL -% 0 CD CD CA M CA CL 0, or — t s CL CD IE CD C- C* M CA ED (C) CD CA CD aj 01 CL's wo CD C* m m co 0 m F;> C/) C/) to 0 \Ko 0 r_ 0 n r z oz I�p t-.*. W) �5 tz C) C-7 UN 0 m F;> C/) C/) to 0 \Ko 0 r_ 0 n r z oz I�p t-.*. W) �5 tz C) UN :s z A� J) co v v r4 "A N, -�m N r LV C) z 0 0 0 )Mh Eel W F 0 CD APPLICATION FOR CERTIFICATE OF OCCUPANCYIINSPEC71ON ADDRESS/1-OCATION OF PROPERTY: -d-) Parcel SUBDIVISION Buildina Permit# Lot Number DATE REQUESTED FILED/READY FOR INSPECTION CLOSING DATE ON PROPERTY: LA* FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. M & Permit Issued to: Address CONSERVATION PLANNING RO TING (o DPW - WATER METER ej 67// k10 7 SEWERMATERCONNECTION rr] &/190 NOTE no DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY1INSPECTION REQUEST DPW Signature File: Application for OC form revised Jan 2007 Registered Architectural and Engineering Services Construction Control Affidavit Project Number: DSA Project #0706.00 Project Title: Edgewood Retirement Community Cottages Project Location: #27 Samuel Way, North Andover, MA 01845 Scope of Project: 22 Individual Cottages In accordance with Section 116.0 of the Massachusetts State Building Code 1, Allen Dewing Jr., MA Registration #4301 being a registered professional engineer/ architect, hereby certify that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project xx Architectural Structural -Mechanical Fire Protection Electrical Other (Specify) For the above named project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code. All acceptable engineering practices and all applicable laws for the proposed project. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 116.2. 1. Review for conformance to the design concept, shop drawings, samples, and other submittals, which are submitted by the contractor in accordance with requirements of the construction documents. 2. Review and approval of the quality control procedures for all code -required materials. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to deternnine, *in general, if the work is being performed in a manner consistent with the construction documents. Upon completion of the Work, I shall the project for occupancy. x�-'O ASC. Dew S�' <C No. 4301 r-oNCORD, IL C, MA 4 0 f as to the satisfactory completion and readiness of FADSA Projecf Files\Edgewood 0706\05. Projecf Word Docurnenfs\a. Correspondence and TransmittalsVi. Misc CHRISTIA�SEN &SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET - HAVERHILL, MASSACHUSETTS 01830-6318 (978) M-0310 FAX: (978) 372-3960 Project No.: 06084' July 15, 2009 .Ms. Judy Tymon Town of North Andover Planning Department 1600 Osgood Street North Andover, MA 0 1845 RE: Edgewood Retirement Community Certifilcate of Occupancy Dear Ms. Tymon: Please consider this letter as a statement of substantial compliance with the approved plans, in accordance with §8.a of the Site Plan Review Special Permit and §10.a of the CCRC Special permit, for the building, landscaping, lighting and site layout for the following units at Edgewood Retirement Community: 9 and 11 Amelia Wa Building, landscaping, lighting and site layout are within substantial compliance with minor modifications made to the building size and site grading; 8, 12, 19 and 27 Samuel Way Building and site layout are within substantial compliance with minor modifications made to the building size and site grading. Landscaping and lighting have not been installed. The landscaping is scheduled to be installed by the end of this month. Christiansen & Sergi, Inc. trusts this is sufficient to satisfy the requirements of the above referenced conditions for occupancy and your office will be able to sign off on certificates of occupancy at your earliest convenience. Should you have any questions or comments please do not hesitate to contact us at the number listed above. Regards, Philip G. Christiansen, P.E. 4 OSA Dewing &Schmid Architects 30 Monument Square Suite 200B Concord, MA 01742 Tel 978.371.7500 Fax 978.371.3388 280 Elm Street South Dartmouth, MA 02748 Tel 508.999.0440 Fax 508.999.7709 www.dsarch.com July 13, 2009 Property Address: #27 Samuel Way Edgewood Retirement Community North Andover, MA 01845 Subject: Final Construction Control Affidavit In accordance with Section 116.0 of the Massachusetts State Building Code, I Allen Dewing Jr., MA Registration #4301, being a registered professional engineer/architect certify that I was present on the construction site on a regular basis and observed that work was completed *in accordance with our Construction Documents and the State of Massachusetts Building Code and the requirements of the Town of North Andover and its officials for the construction of the dwelling referenced above. No. 4301 ) 1��4 7 /.3 CONCORD, I/Allen De% g �Jr. Date MA A Dat'. ,� .................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4a 'This certifies that ................................ .......................... has permission to perform wiring in the building of ...... * at........... Fee.4&d ... .... Lic. No�'�cA Check # 8601 ............. North Andov6r',IMass. ............. . E �I :.J \ %� (r Official Use Onty I\_ Commonwealth of Massachusetts Permit No. Department of Fire Services Occupancy and Fee Checked/? 1-1-9 BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (1,aveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfornied in accordance with the Massachusetts Electrical, Code (Mp, 27 CMR 12.00 PE ALL INFORAL4 TION) Date: 910 09 (PLEASE PRflVT IN LVK OR TY 11 City or Town of' A)QRrU Ak� VfE JE To the Inspector �f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street& Number) al ISAM(Arlz IAL� W Owner or Tenant 16J)QF".j4)6on_ Rwjnemrtk�r cammy)L)ITJ Telephone NO'. Owner's Address Is this permit in conjunction with a building permit? Yes No (Check XppropriAte Box) Purpose of Building E:�) L I I-)& Utility Authorization No. Existing Service Amps Volts Overhead Und-rd No. of Meters New Service Amps ]-2,p. 2.,-31V Volts Overhead Undgrd No. of Meters Number of Feeders and Ampacity - 2 oon 121 Location and Nature of Proposed Electrical Work: wjk_� Comnietion of the following table inav be waived bi) the Inspector of Wires. No. of Recessed Luminaire s 0) D, No. of Ceil.-Susp. (Paddle) Fans L/ No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires mmin- Pool Above El In- Sw' grnd. grnd. No. ot Lmergency Lighting 1,BatteKy Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS JNo. of Zones No. of Switches No. of Gas Burners JNo. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total i Tons INo. of Alerting Devices No. of Waste Disposers Heat Pump Totals: K.�W� ........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Mun'c'P�l El Other Local E Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or E quivalent No. of Water KW Heaters NO. of No. of Signs Ballasts Data Wirina: No. of De'vices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail ifilesired, or as required by the Inspector of Wires. Estimated Value of �lectrical Work: (When required by municipal policy.) Work to Start: A I / 2 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE C-] BOND [I OTHER [I (Specify:) I certify, under the pains andpenalties ofperjuty, that the information on this application is true and complete. FIRM NAME: Interstate Electrical ServicJs .:A-521 7 porporat" LIC. N Licensee: —Pasquale A. Alibrandi Signature I 11 — M= (1fapol' bl Ver I in [he license number line.) Bus. Tel. No.:978-66 7- 5 200 'Scs'2 �6` Treexegie Cove Rd. , N. Billerica, MA 01862 Addre : Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) [] owner 11 owner's aszent. Owner/Aaent Signature` Telephone No. PEIVET FEE: S O�t- 9'-,- /-3 - 0 � la-4- 61t- 1::'5'jeq- IQ� .4 y Date ...... 6=0 q1. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............................................................................................. has permission to perform ............ wiring in the building of .............. ..................................... at .,-).7 ....... ....... ....... . North Andover, Mass. Fee ..................... Lic. No. � . . .......... ELEcrRicAL INsPw R'* Check, # 8661 w-ul"manwealth Of MassaChusefts — Official Use C)njy Department of Fire Services Permit No. y Occupancy an�d Fee Checked BOARD OF FIRE PREVENTION REGULATIONS FrReVrl/n APPLICATION FOR PERMIT TO PERFO (leave blank All work to be performed in accordance with the M RM ELECTRICAL WORK (PLE4SEPMTNR�WOR TYPEALL NFORW assaChusetts Electrical Code (MEq, 527 CMR 12.00 City or Town oft NORTH ANDO TJOA9 Date: 3 By this applicatiofi- VER the undersig.;J Tgie, TO the Inspe tor of Wire,: "f�_ "� c Location (Street & Number) 11P 7 er intention to Perform the electrical work described below. J Owner or Tenant C7-/ --------------- — Owner9s Address Telephone No. 11 this permit in conjun cti 0 n wi t h a buildin Z�cVg pe�rmiit? Purpose of Building % Yes 0 No (Check Appropriate Box) ;Wle >1ja ALIA1421 �#� Utility Authorization No. �-rxisting Service Amps Lew Service Amps volts Overhead Undgrd No. of Meters Volts OverheadEl UndgrdE] Number of Feeders andAmpacity No. of Meters Location and Nature of Proposed Electrical Work: 0. of Recessed Luminaires 0. of Luniinaire Outlets of Luminaires No. of Receptacle Outlets No- of Switches No. of Ranges No. Of Waste Disposers ------------ No. of Dishwashers 0. of Dryers ___W 0. of ate—r Heaters KW 0. Hydromassage Bathtubs OTHER: Sip In e no e No. of CeiL-Susp. (Paddle) Fans No. of Hot Tubs swimming Pool Above c-rrnd- of Oil Buxners No. of Gas Blumers ------------ — No. of Air Con& SPace/Area Heating KW Heating Apphainces 'KW No. of 0. of __E!P_S Baflasts of Motors Total HP m . n table may be waived by the ku5!Ector of Wires. a. of Totg— Transformers KVA Generators KVA F-1 10.0 mergency Ratte Units FIRE ALARMS No. of Zones O_O etection and imitia * Devices No. of Alerting Devices 0. of e ontained Detection/Ale '* a, Devices � unicipa 110 11 r1onnection Other See tY S tems: - No.of evicesorE uivalent Data Wiring: No. of Devices (L _2LE uivalent Telecoammm icad ns — g: No. of Devices or Riallivala.+ Estimated Value of Electrical Work.- Attach additional detail trdesired, or as required (When required by municipal policy.) Work to Start:? Inspections to be requested in accordance with MEC Rule 10, and upon completion. INS URANCCCOVE"GE- Unless waived by the owner, no Permit for the Performance the licensee Provides Proof of liability insurance including 11 of electrical work may issue unless undersigned certifies that such coverage is in force, and has Completed Operation" coverage or its substantial equivalent The CHECK ONE: INSURANCE exhibited Proof of same to the permit issuing office. 2" BOND 13 OTHER EJ (Specify:) I certiY, under thepains andpenaldes ofperjury, that th FIRM N ,–. I I e information on this application is AME:_V/1 41- � I " I true and comple�4 Licensee: sit LIC. No.. (7f applicab le, enter "exe in I e license LrC. NO.: Z_2_i171) X s:, 1 4 A Addres V - Bus. Tel. *Per M. G.L c. 14 7, s. 5 security work requires AIL Tel. No.: OWNERIS INSURANCE WAIVER: I cPartment of Public Safety "S" License: Lic. No. am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one) o er El owner's agent Owner/Agrent Siu ft Wn-- L J Z, a ,nature Telephone No. IN The Common wealth of Massachusetts Department of Indus&iid Accidents Office of Investigations 600 JEashington Street Boston, MA 02111 www.nzass.gov1dia Workers, compensation Insiwance Affidavit. Buflders/ContractorslElectricians/Plumbers linfle2nt Tnfay..+;-- Nan�e (Business/orguizafion/individual): 5) /// lVe--- ApltonAA "o 14,1110, Address: :.2- City/State/Zip: Phone #: - 9� 7J - 42 - 6 Y7 �/_V Are 11 employer? Check -the appropriate box: I. Y0,1111 a I I : am a employer with 4.7 1 am a general contr*aaor and I Type of project (required): employees (full and/or part-time).* I am asole Proprietor have hired the silb-contractors listed 6. 21-4ew construction 7- or partner- on the attached sheet DRernodeling ship and have no employees These sub -contractors have S. Demoi . iti.on working for mei n* any capacity. [No workers' comp. insurance workers' comp. insurance. S. El We are a corporation and its 9. Building addition required-] 3.[] 1 am 8 homeowner doing officers. have exercised their 10. D Electrical repairs or addifions all work right of exemption per MOL I I.0 Plumbin repairs oradditions 9 myself, [No-workers'comp. insurance required.] t c. 152, § 1 (4), and we have no employees, [No workers' 12.[] Roof repairs comp. insurance require4i 13 -El Other *AnY RPPli-nt ftt checks bwe #I tw also fill ou- t tthesection below showing their worked' compensation policy mformation. Homcowne�s who submit this afrldzvit indicating they am doring -all work and then him outside con tnictors must submit 4conftctors that a new affidavit indicating such. check this box must attached an additional sheet showing. the name of the sub-cOntnicton; and their worict.-s'coomp. p--!., CV, ;,,na�on. am an employer thx is prqvidingworkers, compensadon insurancefor my employee information. Below is the.pogcy andjob site Insurance Company Name: xe Policy 9 or Self -ins. Lie. W6- Z,.3 rg S--1 k Expiration Date: Job Site Address:d _,7 Ci1y/Statt-_/Zip:N. 9-,uoeryf,4� Attach a copy �f the wor . _ ___ - kew- c0fnllens�ation -policy declaration page �showingAhe policy n umber and eXpiration date� Failure to secure cove -,age as required under Section 25A of MGL c. 152 can lead to the imposition of craninal penalties of a fine up to $1,500-00 and/or one-year imprisonment, as well as civil penalties in the form of a 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 unde� the pains andpenalties ofperjury that the information Provided above is true and correct ------- Phone#: 9 7.P- 1, V -7 Officiat use tonly. Do not write in this area, to be completed by c4 or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitY/Town Clerk 4. Electrical Inspector 6. Other — 5. Plumbing Inspector Contact Person: Phone #.— Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An eniplayer is: defined as "an individual, partnership,assc)diatian, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a de=ased employer, or the receiver or timstee-of an individual, partnership, association or other legal entity, empioyingem-pioyees. 'However the owner ' -of a dwelling house having not more thah three apartments and who resides therein, or the occupant of the dwelling house of another, who employs persons to do maimtenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of sucb employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opemte a busmiess or ito construct buildings in the commonwealth for any applicant who has not produced acceptable evidence oir compliance 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 until acceptable evidence of comphince with the insurance requirements of this chapter have been presented to the cointracting authority." Applicants Please fill out the workers' compensation. affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone munber(s) along with their certificate(s) of insunance. Limited Liability Companies (LLC) or Limited Liability. Partnerships (LLP) with no employees other than the members or partners, are not required: to carry workers' cornpmsation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affic ' lavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the peim'it or license is being requested, notthe Department of industrial Accidents.. Should you have any questions regarding the law or if you are 'required to obtain a workers' compensation policy. pleasetall the Department at the number listed below. Self-insured companies should enter their self-insuranc*e license number on the* appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of lnves�igations has to contact you regarding the applicant. Please be sure to fill in the permitflicense number which mill be used as a reference number. In addition, an ap'plicant that must submit multiple permitAicerrise applications in any given year, need only submit one affidavit indicating-currurit policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or town)." A copy of the affidavit that has been officially starnped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for firtmn permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required t o complete this affidaviL The Office of Investiptions would like to thank you in advance for your cooptration and should you have any questions, please do not hesitate to give us a call. The Departnient's, address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of linvestiggations 600 Wash-ington Stmet. Boston, MA 02111 Tel. # 617-7274900 eixt 406 or 1-8.77-MASSAFE Fax # 61 7-727-774� Revised 5-26-05 W1VVW.m4_iss.aov/dia C�- Date �A t&ORTPI . TOWN OF NORTH ANDOVER 0 0 PERMIT FOR PLUMBING SS CHUS This certifies that 141.11tle.� . ............ has permission to perform ............ plumbing in the buildings of . C'. j .............. at North Andover Mass. -7- ....... ...... ...... Fee Lic. N o. LUMBING INSPEdOR .Check # 8021 a � � 't ( I haw a current f h*ur4nM Porr-Y or Its sittistantial e**4akwd which meets the requirenierft of MGL CIL 142 Yes ' 50 No ff you hm chedwd Yom Pkaae Inilkate the tfim Of cove by ch0dft 810 appropriate box b Pic A liability. insurance policy 0 Other type of indemnity 0 Bond 0 0VMER'S MtIRANCE WAIVER: 18111 SN810 ISM #10 Kc=M do" not hM the INSIAranCe coverage requkW by Otapter 142 of the 111 � 1, A , g e tie General Lawii6 and that nry signalure an aft permit: application vAdvas this requirenjeft Check One Only Signabire Of owner or ownees Agent Owner 0 . Agent 0 1 herelry cerIfFyontan ofthe deleft and kftnmdon I have Sulunitted (arefter" regarding Oft application we bus and accurate to the beft of my Knawledge arM SM all Plurnift work arx! halaftflow peribruied uWff Me POMM Issued for dds application wM be In cmnflarece wft an U. -I Twe Type of License: Qgpkantier r" RIMIN ff=Zjtnan Lwense Number. 13437 MASSACHUSETTS UNFORM APPLICAYMN FOR PERMIT TO DO PLUMING ClWrown &V M& D,.-.2LfZ6 C -101-1 Penn. SwIdIng Location: I I Owners Name: E Jlcl-ll Type Of Occupancy Commercial 0 Educational 0 Indushial 0 Insfiftitmol 0 ResWIenW Meradon: 0 Renavadom, D Replacernent: Plans'Submitled: Yes 0 No 0 I haw a current f h*ur4nM Porr-Y or Its sittistantial e**4akwd which meets the requirenierft of MGL CIL 142 Yes ' 50 No ff you hm chedwd Yom Pkaae Inilkate the tfim Of cove by ch0dft 810 appropriate box b Pic A liability. insurance policy 0 Other type of indemnity 0 Bond 0 0VMER'S MtIRANCE WAIVER: 18111 SN810 ISM #10 Kc=M do" not hM the INSIAranCe coverage requkW by Otapter 142 of the 111 � 1, A , g e tie General Lawii6 and that nry signalure an aft permit: application vAdvas this requirenjeft Check One Only Signabire Of owner or ownees Agent Owner 0 . Agent 0 1 herelry cerIfFyontan ofthe deleft and kftnmdon I have Sulunitted (arefter" regarding Oft application we bus and accurate to the beft of my Knawledge arM SM all Plurnift work arx! halaftflow peribruied uWff Me POMM Issued for dds application wM be In cmnflarece wft an U. -I Twe Type of License: Qgpkantier r" RIMIN ff=Zjtnan Lwense Number. 13437 -M MMMMMMMMMMMMMM inswing.compain yName-. In Addnnw 'BusinessTOI-. FwcM#==-5-410 Name of Licensed Plumber.Ti d I haw a current f h*ur4nM Porr-Y or Its sittistantial e**4akwd which meets the requirenierft of MGL CIL 142 Yes ' 50 No ff you hm chedwd Yom Pkaae Inilkate the tfim Of cove by ch0dft 810 appropriate box b Pic A liability. insurance policy 0 Other type of indemnity 0 Bond 0 0VMER'S MtIRANCE WAIVER: 18111 SN810 ISM #10 Kc=M do" not hM the INSIAranCe coverage requkW by Otapter 142 of the 111 � 1, A , g e tie General Lawii6 and that nry signalure an aft permit: application vAdvas this requirenjeft Check One Only Signabire Of owner or ownees Agent Owner 0 . Agent 0 1 herelry cerIfFyontan ofthe deleft and kftnmdon I have Sulunitted (arefter" regarding Oft application we bus and accurate to the beft of my Knawledge arM SM all Plurnift work arx! halaftflow peribruied uWff Me POMM Issued for dds application wM be In cmnflarece wft an U. -I Twe Type of License: Qgpkantier r" RIMIN ff=Zjtnan Lwense Number. 13437 Date ............. TOWN OF NORTH AND' ER PERMIT FOR GAS INSTALLATION --V ........ T ,bis certifies that ............... haspermission for gas installati n A� in the buildings of ....... at C�l .. ................ North Andover, Mass. Fee/A-n .... Lic .......... GAS INSPECTOR Check # 6 7 r 8 0 Installing conipany Business Name of Licensed PlumfmfGas F INDUKANUr. WVftMU= I have a current F knumme policy or Us substantial etiumalent which meets the requireinents of NGL Ch. M Yes §1 Nob V.Tyou have chedmd Yes. plesseindftaft the type of =were" by chedft to appfopft% box below. A liability Insurance policy Other type of indemnity 1101W El OWNEWS WISMANCE WAMR. I am aware that the lkwom dg2LggLbM2 the Insurance coverage required by Chapter 142 of the General Laws, and that ary signaUffe an this permit application ymbm this requbwnenL Check Orm Only Owner 0 Agent 0 By thedft Mb box U; I hweW Gerft dW SO of the detaft and hdonnation I ham autindtled (or entered) reganfing dds appNeadw we true and ataxate toldta best of fay Knowledge and that A pkmd*g Item andinstalladonspeften under the paindt Issued fbr dds appocaftn wM be In wfth aff Pertinent pwielon of the Massadumens State Munhibig Cqft and Chapter 142 of the Genwal Laws. a - or WA Waal 0 JIFJ MASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO Do GAS FITTING CitylTawn:./V I J4za r— MA. Date: kz Penniff Bulltllng Locatlowo?, owneremlenw. Irl -i RL re- TypeofOcwpancy: Qmm*wCWID Educational[] Industrialo lnsftAona]O ResidentialEr 2 Nqwjq`AfteratIon:0 Renovation:[] Replacens 51,.0 Plans Submitted: Yes [I Noo Installing conipany Business Name of Licensed PlumfmfGas F INDUKANUr. WVftMU= I have a current F knumme policy or Us substantial etiumalent which meets the requireinents of NGL Ch. M Yes §1 Nob V.Tyou have chedmd Yes. plesseindftaft the type of =were" by chedft to appfopft% box below. A liability Insurance policy Other type of indemnity 1101W El OWNEWS WISMANCE WAMR. I am aware that the lkwom dg2LggLbM2 the Insurance coverage required by Chapter 142 of the General Laws, and that ary signaUffe an this permit application ymbm this requbwnenL Check Orm Only Owner 0 Agent 0 By thedft Mb box U; I hweW Gerft dW SO of the detaft and hdonnation I ham autindtled (or entered) reganfing dds appNeadw we true and ataxate toldta best of fay Knowledge and that A pkmd*g Item andinstalladonspeften under the paindt Issued fbr dds appocaftn wM be In wfth aff Pertinent pwielon of the Massadumens State Munhibig Cqft and Chapter 142 of the Genwal Laws. a - or WA Waal 0 JIFJ It lu 2 Z JK W 1- a 2 2 0 0 !-C Ul tu 0 x oe z 0 13 z _3 — 0 lu z a 0 W W CUD, Wz W` 0 0 1�_ 1�_ 0 Ul f- 0 lu is rc X jE Ul Z I 0 a x z A IS a 1- W x W W W 0 Z 0 I= I I z W P x 0 a x 1 0 IL z > 0 Installing conipany Business Name of Licensed PlumfmfGas F INDUKANUr. WVftMU= I have a current F knumme policy or Us substantial etiumalent which meets the requireinents of NGL Ch. M Yes §1 Nob V.Tyou have chedmd Yes. plesseindftaft the type of =were" by chedft to appfopft% box below. A liability Insurance policy Other type of indemnity 1101W El OWNEWS WISMANCE WAMR. I am aware that the lkwom dg2LggLbM2 the Insurance coverage required by Chapter 142 of the General Laws, and that ary signaUffe an this permit application ymbm this requbwnenL Check Orm Only Owner 0 Agent 0 By thedft Mb box U; I hweW Gerft dW SO of the detaft and hdonnation I ham autindtled (or entered) reganfing dds appNeadw we true and ataxate toldta best of fay Knowledge and that A pkmd*g Item andinstalladonspeften under the paindt Issued fbr dds appocaftn wM be In wfth aff Pertinent pwielon of the Massadumens State Munhibig Cqft and Chapter 142 of the Genwal Laws. a - or WA Waal 0 JIFJ