HomeMy WebLinkAboutMiscellaneous - 29 ANDREW CIRCLE 4/30/20181p
North Andover Board of Assessors Public Access
*LORT"
CHU
Click Seal To Retum
Search for Parcels
Search for Sales
Summary
Residence
Detached Structure
Condo
Commercial
Page I of I
North Andover Board of Assessors
m7m%,
7zroperty Record Card
Parcel ID :210/047.0-0130-0000.0 FY:2013 Community: North Andover
SKETCH
Click on Sketch to Enlarge
PHOTO
Click on Photo to
29ANDREW
Location: 29 ANDREW CIRCLE
MAILHOT, EDWARD G
Owner Name:
JOAN IT MAILHOT
Owner Address: 29 ANDREW CIRCLE
City: NORTH ANDOVER State: MA
Zip: 01845
Neighborhood: 5 - 5 Land Area:
0.07 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area:
1152 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 205,600 209,800
Building Value: 72,200 72,800
Land Value: 133,400 137,000
Market Land Value: 133,400
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkId=2253457&town=NandoverPubAcc 3/26/2013
CDOXWU
76 6' (1)
a -t5 �5 of L
t C), C)
a) co
CL m
CL a)
r_ (j) 0�
2 w C) s 0
IL
LL 0
CL:R
ui ��Y
o ii L:
L) 1F= 2
ca
0 '0
L)
LLI
U—) M:
z � (D
LO 04
CD CD
L)
CY) ----Q
70
Z6 w 00 m:,, a)
L) W CO IL 0
-"o 12 i
00
L) <
Ilf _j 0 co <
LLJ 0 e
co
C) 0
(D
a w C� ;6 a.
2 < � cD
Q- 0-
- J0,
ca CD 0.=,
CD a- oeg�> 0
a) cm 4) a) 4)
-0 0 —
CD
(n U) (n (n 0
0
eq
Ln
cn 0
0
j -a (n < -0
CO 0 Cc
Q
C'n
CL
CD
Z
0
— I
-.0
-i
ib
'0
.s
E
0
L)
0
r
I
00
00
co
0
LL
CD
,It 0
C —
LU
0 W LLI
>
CM
L)
00
W
IL
- LU Z
� w <
w
0 LL rm x
z �i z
L)
L:
a) go 200
Z
0
I
0
Cl)
co
cc
C)
CD
9
0
co
C)
Z
2
ca
a_
00
00
,It 0
to
U)
cli rl:
Cl) Cl)
(o
Cli
> co
C) 0
C) 0
1;T 0
iz
cli P.:
Cl) CY)
Z
i�
m
z 1* 11,
0
1--
-
m m
0 It
0
C�
LL.
0 N'o q
o C>
C 0
Z 0 C)
N co
LL
z
z Cq cli
Lo.
LL 0
z &CD
. . . . . . . .
0
L) 0
>
U)
0 0
C) 0
z
V
0
Lc) 0--
(C� cq
CY)
0 C)
C\l 04
Z,
�6
V4 )s R
z
LLI
j.
4)
cm
0 RL,
0 0
L) 1--
0
F-
0
ca 40))
]z
Z C-4
L)
40 C14
w 04
P- I- o OR C14
Lf) Cn m CD I -
co
"0
2
0
<�E (D
U)
z
LL
U) c: V) L) 0�, CD
2 0
CO LL M ly (n 0
4)
M
Z
cli co co I
to W, LO r- r-
Q
0
t, r-- 1 0) (D
LO Lo
0
m Co co
co 2 i� 2
0
LL
- 2 < 2 < '5 =
< M =3 g�E
LL co 0
m
Z
0
C LL C FL -'a-00 0
LL
w
.c 'a = (u (o c I t5 (D
6 CL -0 r- (D 0
�
L)
2 D D w L) (L -.0
z
LU
W) C,4 o F-
m
cc
W
W
i6 U) LL
E E CU
=3.2 m
0
0 C) -Z6
0 co 00
CL co
Of 2 ca -C E;,E
75 0) U m:t:: U) U)
M �LL Y- w m Y Lu co �m
CD, 1
R. > z 3.
C-4
E
C)
CL
4)
a
>
5, C,
m c �o �-
o C:
L)
w
0 U)
o
0
3:1
JU) U) af w �i uo- M LL
a.
U)
0
Cl)
co
cc
C)
CD
9
0
co
C)
Z
2
ca
a_
L
78UG Date. �: ..........
.6NO,
A TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation .........
in the buildings of AIAII�Iele� .......................
at I.. Ar7 .......... North Andover, Mass.
Ile
Fee Lic. No.. "R .........................
GASINSPECTOR
Check # 2
a�l MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:,.../"3, Date: Permit#j ..... . .. ...
Building Locatic'1;)9.AA0yr-- /-,,P - Owners Name:
Residential!
Type of Occupancy: Commercial Educational, 1�1 IndustrialF lnstitutional�
Alteration:�
New: Renovation d Y
L- �, Replacement: Plans Submitte es\,.' No�',
FIXTHRIF-9
INSURANCE COVERAGE: - —� "1 -1. 1 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes V( -,No_-- !
If you have checked Yes, please indicate the 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
Owner Agent If I
Siqnature of Owner or Owner's Aaent
By checking this box E]; I hereby certify that all of the details and information I have submitted (or entered) regarding this 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 will be in
compliance with all Pertineqt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
-,—,Type of License:
By
Plumber
Title
Gas Fitter
Signature of Licensed Plumber/Gas��
C6
Master
City/Town . .... ........ .... ...... . . .. . ...... .. .
Journeyman
LLI uj
Z I.-
U)
LP Installer
0
0
LLI W U
0
w
uj
z
g
(9-j>-
ZF)W
IX
W
U)Ozww
IX
0 z
V5 Lu U)
W
uj
0
�-
<
iL
Luwol�-=)
1.-
a
0
W
X
>
IX U)
Lu�—Wowwwkwu)XLLIF-
<
U)
0
<
LU
W
F.-
rL
0 1
> W z
z Lu it
0
U)
—j
_j
0 z
< < M W
_j
0
0
z
ILL
0
U)XZLUWW
I`—
U)
LU
>
I --
z
LU
LU
W
0 :3
0 a 0
<
0
2
0
W W < >
b
0
0
W
z
z
III
P
u-
-1
a.
>
0
SUB BSMT.
BASEMENT
1'-�' FLOOR
2 WFLOOR
3"u FLOOR
4"' FLOOR
5"' FLOOR
-6'
FLOOR
7"' FLOOR
8"' FLOOR
Check One Only Certificate #
Installing Company Name:. Done Right Plumbing & Heating
Corporation
Address:'�,256 Twin Bridge Road
City/Town; New' Bosio`n---."
State: N
. ......
. . .... ... .
Partnership
Business Tel: '6033258127
Fax:
I.Firm/Company
Name of Licensed Plumber/Gas Fitter:[ Marc Tremblay
INSURANCE COVERAGE: - —� "1 -1. 1 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes V( -,No_-- !
If you have checked Yes, please indicate the 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
Owner Agent If I
Siqnature of Owner or Owner's Aaent
By checking this box E]; I hereby certify that all of the details and information I have submitted (or entered) regarding this 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 will be in
compliance with all Pertineqt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
U
i
-,—,Type of License:
By
Plumber
Title
Gas Fitter
Signature of Licensed Plumber/Gas��
Master
City/Town . .... ........ .... ...... . . .. . ...... .. .
Journeyman
.... .....
License Number: 5 PL 15479M
APPROVED (OFFICE USE ONLY)
LP Installer
U
i
State of N "",-,Hampshire
GAS FITTERS4,1211C NSE
NAME: MARC TREMBLANL
ENDORSEMENT S
gi
Oil Burner Technician Cerfificate
iP.11
DATE ISSUED: 12/02/2010
z
DATE EXPIRES: 12/31/2012
LICENSE #: GFE0801251
I
,�7
DEPARTMENT OF PUBLIC SAFETY
gi
Oil Burner Technician Cerfificate
iP.11
Number:, BU 112864
Epires: 1210212,011 Tr. no: 2528.0
Restricted: 00:', -
MARC TREMBLAY
256 TWIN RIDGE klD,
NEW BOSTON,
NH 05070
Commissioner
. ........... . . .....
I
4
,3.'2- N(�&PvJ c-ctc(—
Location 30 vAydLui ctcc
No. (,, C 4 - ('5'3 Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ 4926
S CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
e
91 '19 Building Inspector
v4ORTH
TOWN OF NORTH ANDOVER
TION FOR PLAN EXAMINATION
APPLICA
SA U
Permit NO:- Date Received: ota
Date Issued: 6
I Al M) R I ix N 11':
liCant 111LISt complete all items Oil this pagc
LOCATION- A v, dife- & i
PROP E RTYO\VNE R
I MAP NO.: O'q Z__0 PARCEL -0 1-31
TYPE AND USE OF BUILDING
r -.M -
ZONING DISTRICT:
"1IQqrd_%1311d_ nVoIr" lrl�
TYPE 01- IMPROVEMENT
PROPOSED USE
I L11 Li
Resideiitial
ori- R.-sidemial
New Building
itB
A Add 101
ddition
A Itel -
lteratiori
XOne farnily
Two or more fami I),
No. Of L111itS:
hidUstrial I
Commercial
>(Rcpaii
I , replacemem
Demolitioii
Assessory Bldg
Moving relocatioll)
Other
Others:
Foundationonly
DESCRIPTION OF WORK TO
RF PRFFC)PX/fvT) �q I ----T-- 71
MM
Identification Plegse Type or Print Clearly)
OWNER: Name:_11-/_ Phone:
Sip
,nature
Address: 3e9 <;�;�A-_
CONTRACTOR Name:
I
/7-3 — 045'e -V
Address:_ gK,
Supervisor's ConstrUCtion License: Exp. Date:
I Ionic lnlpro�enlcnt IJcC11SC:.__. Exp. Date:
a
k R Cl -1 ITL C' E 1, N G I N F 1: R
Name: Phone:
Address:
Reg. No
FEE SCHEDULE: BULDING PERMIT 810. of) PER Sl(()). OF THE TOTAL EST1,41-1 TED COST B.4,VD ON
5 125. 00 PER S. F. t
Total Pro ect Cost 049
J '74 %Jj x10.00 FEE:$ �&3
Check No.:_ Receipt No.:
T_r__
_L_ �
TYPE OF SE\�ARGE DISPOSAL
PUbli(. Se%vcl-
pl-i\ate (septic tank, etc.
Tannin,,'%1lassa,,,.e Body Art
Tobacco Sales
1 vernianent Dunipster oil Site
SN'villinlintg Pools
i Food Packaging Sales
I - Z�
is voutnictill" with unregisleretl c-ontraelors (h) not have tweess to the gutirantrPintl
NOTE: Persot
Sigjj�iture of',-,XL1-,ejjt/0\vner SignatUre ofContractor
7 ertified Plot Nan *Stampne Plans
Plans Submitted Plans Waived L -j C
T"E FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SICN OFF - U FORM
PLANNING & DEVELOPMENT
4:0MMENTS
CONSERVATION
COMMENTS
I
,.HEALTII
COMMENTS
DATE REJECTED DATE APPROVED
[]Water Shed Special Permit
Lj Site Plan Special Permit
11 Other
DATE REJECTED DATE APPROVED
1-1 � El '
DATE REJECTED
Zoninu Board of Appcals: Variance, Petition NO:
I
ZoniilL Ducisioll,"'CcciPt subiiiitted yes
Hanning Board Dc cisioll:
Conservation Dccisioll:--- coillincilts
k\:ajej- & ScAer coilliecti011 signature &, date
Tnip DLIIIIPStCl- Oil Site Nes__no -/\- Fire Departnient Sil-IllatUre'date
BUilding. Permit Approved and Issued by:
DATE APPROVED
qoo�
UON
1443
6
z
W
R;;
.0 L cc
do; 0 W
CS
CL C
CD C
CD
Es
C4 0
C"
GO m
0
Clt. E= 0
0 0 cm
CLC -3 0
a CD CC
cm 02
R
WS
a
0
0 CM
=0 t L A
C =CD =0
CD COL 0
0
CO2 CD CD
LU g. 4::s 'o
.;; MO
to CL=
CCD
.2 w cm
uj
L.2
CO3 C2 -0
C)
06� cc FO
C/)
0
C/)
P-4
N14
Cf)
C/)
z
0
u
Cf)
cot)
a
0
;:Fs
Ell
u
"T3
TIT
w
P4
4-4
CD
0
E
co
0
ts
CD
CL.
CD cm
a
CO3
.co) CD
g ca cc
CD CD CD
L- 1�– =
CL — *"
4D
C.*
Cc
C43 ts
CD
0 CL.
CO2
CL.
w
Ck
U)
w
U)
19
w
w
LLI
CO)
,a
0
�E
V)
u
0.
V)
u
w
00
LE
E
u
–cri
x
w
0
co
–cz
UW
-C
ZW
0
.0 L cc
do; 0 W
CS
CL C
CD C
CD
Es
C4 0
C"
GO m
0
Clt. E= 0
0 0 cm
CLC -3 0
a CD CC
cm 02
R
WS
a
0
0 CM
=0 t L A
C =CD =0
CD COL 0
0
CO2 CD CD
LU g. 4::s 'o
.;; MO
to CL=
CCD
.2 w cm
uj
L.2
CO3 C2 -0
C)
06� cc FO
C/)
0
C/)
P-4
N14
Cf)
C/)
z
0
u
Cf)
cot)
a
0
;:Fs
Ell
u
"T3
TIT
w
P4
4-4
CD
0
E
co
0
ts
CD
CL.
CD cm
a
CO3
.co) CD
g ca cc
CD CD CD
L- 1�– =
CL — *"
4D
C.*
Cc
C43 ts
CD
0 CL.
CO2
CL.
w
Ck
U)
w
U)
19
w
w
LLI
CO)
4
4,
bw,W �Kl
AT...,
............
(TO =J4d
Mtv
4
4,
bw,W �Kl
AT...,
PROPOSAL SUBMITFED TO:
E
hA"'k
4pDqESS
,pAT,E'0F PLANS
�ARCHITECT
PHONENO.-
'�3
1.1
WORK TO BE PERFORMED AT
AMDRESS-,
,pAT,E'0F PLANS
�ARCHITECT
'as -specified. Pay n swillbe" ad -outlin6d above.
me 't "e"P 'C'e""aS,
Date S
CV,,-a� NL; �idlt"U
MADE IN USA PROPOSAL
77!-
AJ DESIGNS, INC..
ANTHONY PETRAITIS III
25 JOSEPHINE AVE.
METHUEN, MA 01844 Administrator
BOARD OF B61LDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 086613
Birthdate: 09/29/1971
Expires: 09129/2007 Tr. no: 86613
r1estricted: 00
ANTHONY J PETRAITIS III
25 JOSEPHINE A I VE
METHUEN, MA 019.44,
a":
Administrator'..
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
ow
Registration: 142227
Expiration: 3/23/2008
Private Corporation
AJ DESIGNS, INC..
ANTHONY PETRAITIS III
25 JOSEPHINE AVE.
METHUEN, MA 01844 Administrator
BOARD OF B61LDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 086613
Birthdate: 09/29/1971
Expires: 09129/2007 Tr. no: 86613
r1estricted: 00
ANTHONY J PETRAITIS III
25 JOSEPHINE A I VE
METHUEN, MA 019.44,
a":
Administrator'..
The Commonwealth ofMassachuselts
Department of Industrial 1ccidents
Office of Investigations
600 fVashington Street
%
Boston,,VA 02111
www.111ass.00v1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADMiCant Information Please Print Legibly
Name
Address:
City,,State/Zip: )�oAW
)V. _�9� Phone 4:
Are you an employer? Check the appropriate box: ,
I. F1 I arn a employer with -_ —
4. [11 am a general contractor and I
employees (full and,or �art-time)-*
have hired the sub -contractors
2.0 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
�Ybrkers' comp. insurance.
[No workers' comp. insurance
5. P"We are a corporation and its
required.]
officers have exercised their
3. F1 I arn a horneowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.]
employees. [No workers'
cornp. insurance required.]
Type of project (required):
6. [] New construction
7. i-R-eemodeling
8. E] Demolition
9. [] Building addition
10.[] Electrical repairs or additions
I Ln Plumbing repairs or additions
12.n Roof repairs
13.0 Other
�,\ny applicant that checks box 3 1 must also fill out the section below shoNving their workers' compensation policy information.
+ I lomeowners �vho submit this affidavit indicating they are doing all work and then hire outside contractors niust submit a new affidavit indicating such.
.1 Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers* cornp. policy information.
litm(ineniployerthiiii.sproviiiiiigivorker,v'compensatit)ninsurancefi)rmyempl(�yee.5. Belt) w is the policy andjob site
illfi)rmation.
insurance Company Name:
Policy !.' or Self -ins. Lic. 4:___ Expiration Date:
Job Site Address: City/State/Zip:__
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to Secure coverage as required under Section 25A of `NIGL c. 152 can lead to the imposition of criminal penalties of a
Fine LIP to S 1,500.00 and/or one-year imprisonment, as well its civil penalties in the form of a STOP WORK ORDER and a fine
Of LIP to S250.00 a day against the violator. Be advised that a copy of this staternent may be forwarded to the Office of
Investityations of the DIA for insurance co,,erage verification.
0
I ilo hereby cert�ft under the pains andpenalties qfperjury that the information provitled above is trite and correct.
S i
tylicial use only. Do not write in thiv area, to be conipleted by ei�y or town qfflcial,
City or Town:
Permit/License 4
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Vectrical inspector 5. Plumbing inspector
6. Other
Contact Person: Phone #:
Building Setback (ft.)
Yard
Front Yard Side Yard Reai
Provided
L I red Provide
�d ��RcCjLlircd Prov ides Rcciuircd
DIMENSION
NUmbu of Slories:--
Total land area. sq. ft.:
Total sqUare feet of floor area, based on Fxtcrior dimensions --
1"I I' X I -1i ;:M f A,
Building Department
The following Is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
:j Building Permit Application
-is Removal Form
,j Debi
* Workers Cornp Affidavit
* Photo CopN, Of H.I.C. And,'Or C.S.L. Licenses
-i Copy of Contract
j Floor Plan Or Proposed Interior Work
Addition Or Decks
Li Building Permit Application
zi Form U
ca Surveyed Plot Plan
• Debris Removal Form
• Workers Comp Affidavit
• Photo Copy of H.I.C. And C.S.L. Licenses
ca Copy Of Contract
• Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic
Calculations (If Applicable)
• Mass check Energy Compliance Report (If Applicable)
New Construction (Single and Two Family)
a Building Permit Application
Li Form U
,j Certified Proposed Plot Plan
,:i Photo of H.I.C. And C.S.L. Licenses
* Workers Comp Affidavit
* Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic
Calculations (If Applicable)
,j Copy of Contract
j Mass check Fner.Lyy Compliance Report
In all cases if a iariance or special permit was required the Toi� 11 Clerks Off -ice Must st,1111p tile decision from file Board of,
Appeals ilia( the appeal period is over. The applicant Must then get this recorded at the Registry of Deeds. One copy and proof'
of recording must be submitted -A ith the building application
Doe: INSPLCI-10% %L SEIRN ICES DEPAR rNn,'NT:BFT0R%105
Date.....................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that .................................
has permission for gas installation ..................
in the buildings of ... ....................
at ......................... ; ............ North Andover, Mass.
Fee Lic. No..)'-�-� ...........
GAS INSk6i(DR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
M
ASSACHUSETTS UNIFORM APPUCATION FOR PERMIT TO DO GASFITTING
(Print or Type)
Aj /A pjT�, o L/ eie_ . Mass. Date—A9�/(9 7 /? 7 19 Permit*
Building Location Owners Name 4Z 6JUjA4,D L-
0 A.,j Do ILte, Al A 0 0 Type of Occupan
New 0 Renovation 0 Replacement 2--*' Plans Submitted: No C]
Installing Company Name AE iZ I �7-AM Al A T A f2O Check one: Certificate
Address Corporation
F-- 7 H U e rJ 01 r-1 0 0 Partnership
Business Telephone 1,50�2 — q 5 -7 ( 2--firm/Co.
Name of Licensed Plumber or Gas Fitter -"Ro(AEieT A- -5AMMyqT-jjP(-D
INSURANCE COVERAGE:
I have a curren!jjabilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 64' No 13
If you.�ave checked Yes, please Indicate the type coverage by checking the appropriate box
A liability insurance policy 00"0' Other type of Indemnity 0 Bond 0
4
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 OwnerO Agent C3
I hereby ce" 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 the pe"ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of a.
Tj off, LLicense:
um 4Whiture ot Uce
Plumber niia A r Us "itter
Title tter
er Uoense Number.
Journeyman
N
NMI
Installing Company Name AE iZ I �7-AM Al A T A f2O Check one: Certificate
Address Corporation
F-- 7 H U e rJ 01 r-1 0 0 Partnership
Business Telephone 1,50�2 — q 5 -7 ( 2--firm/Co.
Name of Licensed Plumber or Gas Fitter -"Ro(AEieT A- -5AMMyqT-jjP(-D
INSURANCE COVERAGE:
I have a curren!jjabilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 64' No 13
If you.�ave checked Yes, please Indicate the type coverage by checking the appropriate box
A liability insurance policy 00"0' Other type of Indemnity 0 Bond 0
4
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 OwnerO Agent C3
I hereby ce" 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 the pe"ed for this application be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of a.
Tj off, LLicense:
um 4Whiture ot Uce
Plumber niia A r Us "itter
Title tter
er Uoense Number.
Journeyman
N
LL,
0
c
0
.j
tu
0
z
0
P
0
w
Q.
(A
0
Ix
7-
0
FA
U.
0
UZ,
a
4c
1 1201
a
Z
U.
16
7.
LU
U.
FA
U.
0
UZ,
a
4c
1 1201