HomeMy WebLinkAboutMiscellaneous - 3 GREAT POND ROAD 4/30/2018 (2)� ,i
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This certifies that
2-?- /-
Date..........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
(�, kvT(V,
..........................................................................................................................
has permission to perform ..... &?A
......................................................
wiring in the building of ....... ....... ....... 7 .... & ............. ...... E,
46
at ...
....... ....... ................... -North. Andover, Mass.
kee/?� ......... Lic. No. '4� .... ...
.................... ijxe .. ��. ......
Check # EN AL INsPECTOR
Commonwealth of Massachusetts Official Use Only
[Permit No.
Department of Fire Services PermitNo. -
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. I/o7]
(leave blpl4
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfornied in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEA SE PR fl VT IN INK OR Y YP. E -4 LL ) NFORM TION) Date:. I — I L/
City or Town of: NORTH ANDOVER To the Inspector of Wir�s.-_
By this application the undersigned gives notice of his or her Et—ention to perform the electrical work described below.
Location (Street & Number) 3 EA -r Pwy 7
;� /� 3)
OwnerorTenant eE-_14L7-X TWIJ_�-� TelephoneNo.
Owner's Address N01�7_17' AA/DQ��-/Z
Is this permit in conjunction with a building permit? Yes D NOE] ' (Check Appropriate Box)
Purpose of Building_ 6-P411Y6-,C:: I-,I-,4LL —Utility Authorization No.
Existing Service Amps Volts OverheadF] UndgrdE]
NeW _Service Amps Yolts Overhead Undgrd
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
V
12
No. of Meters
No. of Meters
No. of Recessed Luminaires
—_ 1 1.11
NO. Of Ceil.-Susp. (Paddle) Fan
tabie may be waived by tne Inspector oJ Wires.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool _T_
Above n-
AQ. of Emergency U-glff-ffing
"Iu'
-Frnd. grnd.
- Lt
Battery Units
No. of Receptacle Outlets
No. of Oil Burn ers
IFIREALARM�S
��o.6�fZones
No. of Switches
No. of Gas Burners
No. of—Detection and
PN
nitiating Devices
No. of Ran es
9
u Total
No. of Air Cond. us
Tons
No. Devices
No. of Waste Disposers
HeatFump
P
!!T:0u:tam1Y8::71
Number T_
................ ..... 9M
FofAlerting
No. of Self Contained
Oi - o
T t
..........
e 0
Detection/Alertina Devices
No. of Dishwashers
Space/Area Heating KW
Local Municipal
Loca El Mu F] other
Co]al
Connection
No. of Dryers
Heating Appliances KW
-S—eeurity Systems:*
No. of Water
KW
No. of
No. of Devices or Equivalent
Heaters
Signs - Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP____
rTele-communications Wiring:
I
No. of Devices or Ea uivalent
UKHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Jnspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVER—AGE: 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 operatioif I 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.-
CBECK ONE: INSURLANCE)4 BOND 0 OTBER 0 (Specify:)
certify, under th'Rains andpenalties qfperj*ury, tl� at tile information on this application is true and com
_2' plete.
FIRM NAME - //1 .4 /_ J A 1A 0/1 A-YV
a LIC. NO.: I LQ, -913
Licensee:
._4 a 04-2 (-���IlVv _—Signa ure LTC. NO.:
afaPplicable, enter "exem t" ' th h number line)
Address: Z.,/) Me V_ " / Bus. Tel. No.: 91"? 31as 4
4�2�� Alt. Tel. No.;_510�z Z2�
*Per M.G.ffc. f47, s, 57-61, security Work requires Department of idSafety "S" License: Lic. No.
OWNER'S INSURANCE WAMR: 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 El owner's agent.
Owner/Agent
Signature Telephone No._, PERMITFEE.- $
Piiii
0 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be pennitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
F The Permit Extension Act Was created by Section 173 of Chap—ter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required ($.) 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 151
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass F?1
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass
Failed
Re- Inspection Required D
Inspectors Commenty.—\
Inspectors Signature:
Date:
U
DEBWEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Commonwealth ofMassachusetts
Department oflndustriqlAccW�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
www'.mass.govIdla
Workers' Compensation Insurance Affidavit: BufldersfContractorsfEle.ctricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:-
City/State/Zip: Phone
Are you an employer? Check the appropriate box: -
Typo of project (required):
1. El I am a employer with
4. El I am a general contractor and 1
6. El New constraction
employees (fall and/or part-time).*
2. El I am a sole, proprietor or partner-
have ned the sub -contractors
listed on the attached sheet t
7. E] Remodeling
ship and'have no employees
These sub -contractors have
8. [] Demolition
working for me, in any capacity.
workers' comp. insurance.
9. F1 Building addition
I
[No workers' comp. insurance
5. El We are a corporation and its
10.El Electrical repairs or additions
required.]
3. El I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
1111 Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12.Q RoofrepEdrs
insurance required.) t
employees. [No workers'
13.D Other
comp. insurance required.]
1-�Any applicantthat checks box#1 mustalsofill out the section below showing their workers' compensation policy information.
THomeowners who submitthis affidavit indicating they Iiie doing all work and then hire outside contractors mustsubmit anew affidavit indicating such.
tContractors thatcheckthis box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information.
-Taman employer that isproviding workers' compensation insurancefor my employees. Below is thepolley andjob site
information.
Insurance Company
Policy # or S elf -ins. Lie. ExpirationDate:
Job Site Address: , City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
4 -
Failure to secure coverage as requiredunder Section 25A of MGL o. 152 can lead to the imposition of criminal 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 fmc,
of up to $250.00 a day against the, violator. Be advised that a copy of this statement maybe forwarded to the Office of
'Investigations of the DIA for insurance coverage verification.
I do h er�by certio un der th epains andp en aldes ofperjury M at th e information pro vided ab ove is true an d correct.
Sip -nature: Date:
Official use only. Do not iprite in this area, to be completed by cl(v or town official
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: Phone 9:
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 ofh1re,-
express or implied, oral or written.,,
Ala ein
ploydis defined as "an individual, partnership, association, corporation or other legal entlty� or any two or more
Of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an ' ividual, Partnership, association or other legal eritity� employing employees. However the
ind
owner of a dwelling house having not more than three apartments and who resides thorch 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 building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or lo7cal licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to constiruct buildings in the commonwealth for any
applicant who has not produced -acceptable evidence of 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicahts
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 number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LTLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmationof 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 permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers,
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number 6 the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printedlegibly. The Department has provided a space at the bottom
of the, affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pleas ' e be sure to fill in the permit/license number whichwill be used as a reference number. In addition, an applicant
that must submit multiple permit/license applicationsi any given year, need only'submit one, affidavit indicating current Ir f
policy information (ifnecessary) and under "Job Site Address"' the applicant should write "all locations in (City or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit ii on file for future permits or licenses. Anew affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or'�emilt not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office OfInvestigations'would like to thank you in advance.for your cooperation and should you have any �questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
Tho CommoRmalth of
Departmeat of Indusidal Accidouts.
OfAce of Investigatiom
600 Washiqpu Sfte,�,t
BOStQnMA02111
Teel, 617-727-4900 Qxt 406 or 1-877,MASSAFF,
Revised 5-26-05 Fax # 617-727-7749
Date .....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
41
This certifies that ....
.Mz. ........ ......
has permission to perform . .......... ... .......... ...............
wiring in the buildinj
I Of Ll� T77 ......... �!..7 ...............
at .....
............... ................. t .... ....... . N rth And
(,7 1 q -.! Lo—
Fee..Ir�� .......... Lic. No.
..... ..............
CALIN*'PECTOR
Check #
10613
�L\l Commonwealth of Massachusetts
Department of Fire Service s
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 1 0 t-; I � ___
Occupancy and Fee Checked
I (leave blank)
,.ev. 1/071
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
1 ...- 2 a � / 2
(PLEASE PPJNT IN INK ORTYPE ALL INFORM4 TION) Date:
To th f Wires:
CityorTownofi e Inspector o
By this application the undersig�ed gives notice of his �r_hd to perform the electrical work described -below.
Location (Street & Number) 6W r-FA77 /Z
Owner or Tenant 4f C --IU T r-02- RC --14 L 7-2" T& 1/.!; 7— Telephone
Owner's Address Pa 0/ 7y�c—
Is this permit in conjunction with a building permit? Yes [:] No A (Check Appropriate Box)
Purpose of Building C0MEEtZ_Cl,4L_ flV1L'P11y""- — Utility Authorization No.
Existing Service Amps -Volts
New Service Amps volts.
Number of Feeders and Ampacity
OverheadF-1 .,. Undgrd--[-]
Overhead [] Undgrd 0
No. of Meters
No. of Meters
Location and Nature of Proposed Electrical Work: J lu�;7,_44 L
7— 6-1y T_5�
Comnletion of the followinLy table mav be waived bv the Inspector of Wires.
!No. of Recessed Luminaires
No. of Ceill.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above o In-
grnd. grnd.
No of Emergency Lighting
Baitery Units
No. of Receptacle Outlets
No., of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No-575etection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
um er
*
Ton�s
I *
1. W
11 1
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
-1 Municipal
LocalEl Connection F-1 Other
No. of Dryers
Heating Appliances KW
-Se—curity Systems:*
No. of Devices or Equivalent
No. of Water KW
0.0 No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivaient
OTHER:
Estimated Value of Electrical Work:
Attach additional detail if'desired, or as required by the Inspector of Wires.
(When required by municipal policy.)
4�13
Work to Start: 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 a BOND [I OTHER 0 (Specify:)
I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete.
FIRM NAME: CONTIND FLECTRIC 9 CART.E., I TNr�� LIC. NO.;A 119 8 3
Licensee: LOIJTR CONTTNO Signature LIC. NO. -F
51- 2g7gg
(If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:978-363-54 0
Address: I DnNOITAN D -P - EST NEWBURY MA 1925 Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-6 1, security v�ork requires Depa-rtmeht of Pubfic Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
requiredbylaw. By my signature below, I hereby waive this requirement. lamthe(checkone)E] owner [I owner's agent.
Owner/Agent
Signature Telephone No. ERMIT FEE. $
FP
i
0
Date../7, - 7- 2? - 0 -7
.............................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies t hat ......... &rcDn;v,! � Z ez- 712,
........................................................................
has permission to perfoinI .... 1-10 ...................................................................
wiring in the building of .......
at............................................................................... . North Andover, Mass.
0 ro
xlm'�l ............. 2
Fee.(2-5 .......... Lic. No . ............. ....
Check 4 9 CrMCAL INSP ECTOR
7904
1�11
Commonwealth of Massachusetts
Department of Fire Servi
ices
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. 'We �/,
Occupancy and Fee Checked
I[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be perfon-ned in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 00
(PLEASE PRINT IN INK OR TYPE ALL INFORM TION) Date:—L��-?— TQ7
City or Town of: NORTH ANDOVER To the Inspeclorof Wiresi
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) --� C-7pr-ep)& , (::—>, - -1 0 — -- 1i
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes No F] (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps Volts
New Service �/� �O Amps �00 OVO Volts
Number of Feeders and Ampacity
Overhead 0 Undgrd El No. of Meters
OverheadEl Undgrd 0- No. of Meters
Location and Nature of Proposed Electrical Work: I�E— F
-- C. �� — (b j�Lal -- -t -g
As� - . L:-
Con—letion olfrfh- irr-11-
No. of Recessed Luminaires
w .. X
No. of Cefl.-Susp. (Paddle) Fans
a i r Wires.
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators K -VA
No. of Luminaires
Swimming Pc In-
No—.of Emergency Lighting
grnd.
Baftery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALA
Anes
No. of Switches
No. of Gas Burners
No. oT—Detection and
Initiating Devices
No. of Ranges
Toia-1
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heat ump
-..IKW
-INO-olself-contained
. ..............
otals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local [j Municip�l El Other
Connection
No. of Dryers
Heating Appliances KW
Securit S stems:*
_ystems:
No.
No. of Water
Heaters KW
No. o —No. of
of Devices or Eauivalent
Data Wiring:
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecom ons Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ydesired or as required by the Inspector of Wires.
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,
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.
CHECKONE: INSURANCE15"OND [:1 OTHEREI (Specify:)
Icertify, under thepains andpenallies ofperjury, thatthe information on this application is true andcomplete.
FIRM NAME:Jva Poelol", e— elr—cl-llric LIC. NO. -_61L 6 L
'S NGro&ue V LIC. NO.:
Licensee: Ph-e,;A Signature
'I --
(If applicable, enter '�xempt " in the license numbqr line.) Bus. Tel. No. -779/
ff- " 1�1 7
Address: 10 (5
Alt. Tel. 7
G.L c. 147, s. 57-6 1, security work requires Department of Public Safety "S" License: Lic. No.
*Per M. No..t
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)E] owner Downer's agent.
Owner/Agent
Signature Telephone No.
3-t1l C,/ -69,t- --/- -, /,:?�-
06
--7—To DATE TIME AM
9 PM
p FROM
�PHONE
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o FAX
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0 E-MAILADDRESS - — ------- TSIGNEU-�w�
E] OAN S TO WILL C I� �r--- T URGENT
BACK CALL I� You AGAIN IWA
PHONED[:] I CALL [_] I RETURNED AL SIN
30 1
Date. 1� ......
"ORTH TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLAirmf
This certifies that ...........
..............................
r
has permission for gas installation ..................
in the buildings of ............................................
.......... ..
at ....... N
pxtkAnd'over, Mass.
Fee. .-� ....... Lic. No ........... .... .. .......
iAS INIPECTOW
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MAS!§ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN'G
(Print or Type)
NORTH ANDOVER Mass. Date.
0 ku'llding Location 49 �5T7 X4?,—X Permit # *?oL)3
Owners Namea-z�/";�/,_;
New -7 Renovation Replacement IR -""Plans Submitted
FIXTURES
1%
(Print or
Installing
Type)
Company Name
Check
one: Certificate
Corp.
Address
F-1
Partner.
Firm/Co.
-Business Telephone:
Name of Licensed Plumber or Gas Fitter
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2ND FLOOR
3RD FLOOR
4TKFLOOR
STH FLOOR
6TH FLOOR
7TK FLOOR
L8�14 FLO�R
(Print or
Installing
Type)
Company Name
Check
one: Certificate
Corp.
Address
F-1
Partner.
Firm/Co.
-Business Telephone:
Name of Licensed Plumber or Gas Fitter
Insurance Coverag Indicate the type of insurance coverage by checking the
appropriate box: —1 Bond Ej
Liability insurance policy [��Other type of indemnity F
Insura@ce Waiver: 1, the undersigned, have been made aware that the licensee of
this a0plication Joes not have, any one of the above three insurance coverages.
Signature of owner/agent of property Owner F� Agent M
I hereby certify that all of the details and infornixtion I haye submitted (or entered) in above application are ftue and accurate to the best of my
knowledge and that all plumbing work and WtitHations petforniod under'Petmit issLed foz this application will -be -In oompliance with an pertinent
provisions of the MAssachusetts State Gas CDde and Chapter 142 of tho General Laws.
By
Title
City/Town:
APPROVED (OFFICE USE ONLY)
.TYPE LICENSE:
Plumber
'to -'6a- s f itter Sicdiature of Licensed
/Plumber or GaAf
so M.a s ter _itter
-M Journeyman ALI�
License Number
MAS�§ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTJ N-()
(Print or Type)
NORTH ANDOVER Mass.
Datej io,/
1huilding Location Z. r
<9 Permit #
-77
T -
Owners Name7X1L/-,0dL4,' Adtl#
New -7 Renovation Replacement fg--"—Plans Submitted
(Print or Type) Check one: Certificate
Installing Company Name -T T14? 1e--'1W1Wf Corp.
Address r Partner.
e— I.L te, [�—Firm/Co.
Business Telephone: h T� '!!� ff 2— D
Name of Licensed Plumber or Gas Fitter
lnsurance_���era�e: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy ED-t-ther type of indemnity F --j Bond Ej
Insurance Waiver: 1, 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 17 Agent El
I hcgcby certify that ail of the dc(AUs and infocniXtiOn I have submitted (or entered) in above application arc true and accurate to the t;,cgt of my
knowledge and that ati p(umbing work and instailations PcIfOrRIOd Under'Permit iuLed fo&- this appUcation wW-bc-in compLiance with &a Pertinent
Provisions of the Massachusetts State Cas Code snd Chapter 142 of the Cencral Laws.
By
Title
City/Town:
APPROVED (OFFiCE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter.
1 -faster
Journeyman
Signat3llre of Licensed
Plumber or Gasfitter
�;--j � L
Licens& Number
(140"A�
MENEM
mom
MINIME
ME
EMEME
MEMNON
HEMERMINIME
MMEMMMIM
MIMMIMMIMMUMMEN
mom
ME
SOMEONE
Eno
MEMO
1-111241-1-11
IMIMEMEMMEME
BMWENEEMSEEM
MESON
monsommon
(Print or Type) Check one: Certificate
Installing Company Name -T T14? 1e--'1W1Wf Corp.
Address r Partner.
e— I.L te, [�—Firm/Co.
Business Telephone: h T� '!!� ff 2— D
Name of Licensed Plumber or Gas Fitter
lnsurance_���era�e: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy ED-t-ther type of indemnity F --j Bond Ej
Insurance Waiver: 1, 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 17 Agent El
I hcgcby certify that ail of the dc(AUs and infocniXtiOn I have submitted (or entered) in above application arc true and accurate to the t;,cgt of my
knowledge and that ati p(umbing work and instailations PcIfOrRIOd Under'Permit iuLed fo&- this appUcation wW-bc-in compLiance with &a Pertinent
Provisions of the Massachusetts State Cas Code snd Chapter 142 of the Cencral Laws.
By
Title
City/Town:
APPROVED (OFFiCE USE ONLY)
TYPE LICENSE:
Plumber
Gasfitter.
1 -faster
Journeyman
Signat3llre of Licensed
Plumber or Gasfitter
�;--j � L
Licens& Number
(140"A�
7' TI Date. . C4
2177
Of 04.4 TOWN OF NORTH ANDOVER
'6,
6 6
'0 PERMIT FOR GAS INSTALLATION
This certifies that 5 C'4- (-ell I, 'I -'Q-
........ I ...................
has permission for gas installation ...
in the buildings of .,/V..1(..0.1P.'1,-1� . '�:41(
at ........... North Andover, Mass.
Fe/p.-�q. Lic. ........... ...... I .......
C V 4 6— t GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File